Cardiopulmonary Bypass

Principles and Techniques

I
II
III
Cardiopulmonary Bypass Principles and Techniques
Author : Mohammad Ibrahim Barham . CCP .n
Edited by : Mohammad Ibrahim Barham . CCP .
modjo1986@hotmail.com modjo19799@gmail.com

Copyright 2016 . by : Mohammad Ibrahim Barham .m

Publisher : Amwaj for Publishing and Distribution .m
For further information on Publishing , visit our website :m
amwajpub@yahoo.com www.amwaj-pub.com
nnnnnnnn -www.scribd.com

Telephone Number: 0096264889615 \ 0096264888361

A catalog record for this publication is available from

National Library of Jordan - Deposit No: 2016/3/1052
ISBN: 978-9957-597-45-0

I have made every effort to provide accurate and up-to-date

information which is in accordance with accepted standards
current recommendations, and good level of practice at the
time of publication. Nevertheless , the author and publishers
cant make warranties that the information contained herein
is totally free from error , because clinical standards are
constantly changing with ongoing research , equipment
development, and changes in governmental regulations .
Therefore, the author and publishers are not responsible for
errors or any outcomes related to the use of material
contained in this book. Wherefore, we advised to pay careful
attention to the information provided by the manufacturer
of any drugs or equipment that you plan to use. We highly
advice you to consult your local authorities and guidelines
for debatable issues.

IV
VI
 Dedication
mmmmmThis book is dedicated to the person who granted
me the motivation for the development in this field. The full
manners person ,the humble man ,the skilful pediatric cardiac
surgeon , doctor Yousef Zurikat .m

mmmmA special thanks to my family , and in particular my

mother, my father , my wife and my children for ttheir love,
and support . I am so grateful for their patience and tolerance
when I was under stress , as I was busy and worked many
hours at weekends , vacations , early morning , and late

evening . so that I could complete this book .m

mmmm I also would like to thank the director of

Queen Alia Heart Institute doctor Saad Jaber for his efforts
to made this book a reality.m

mmmmI would like to acknowledge the tireless efforts

of the reviewers for diligence in improving the language
and grammar of the text , in particular doctor Zeid
Makahleh , doctor Ashraf Fadel Moh'd , and doctor Salah
AL-Tarabsheh .m

Mohammad Barham. CCP.

VII
 Contributors and Reviewers
Saad Jaber ,MD, Consultant Cardiac Surgeon, Director of Queen Alia Heart
Institute, King Hussein Medical Center(KHMC), Royal Medical Services(RMS), Jordan
Armed Forces(JAF).
Yousef Zurikat ,MD, FRCSI, Senior Consultant Cardiac Surgeon, Chief of Cardiac
Surgery, Queen Alia Heart Institute, KHMC, Royal Medical Services(RMS), Jordan Armed
Forces(JAF).
Abdel-Fatah mohd Abu Haweleh, MD ,MRCP, BCCA, Chief of pediatric and
congenital cardiologist, Queen Alia Heart Institute, KHMC, Royal Medical Services of
Jordanian Armed Forces.
Yaser Al-Ghoul, MD, JBA, Consultant of Cardiac Anaesthesia, Queen Alia Heart
Institute, KHMC, Royal Medical Services of Jordanian Armed Forces.
Ali Abu Rumman, MD, Consultant of Cardiac Surgery, Queen Alia Heart Institute,
KHMC, Royal Medical Services of Jordanian Armed Forces.
Zeid Makahleh, FRCS (C-TH), Consultant Cardiac Surgeon, Queen Alia Heart
Institute, King Hussein Medical Centre, Royal Medical Services of Jordanian Armed
Forces.
Ashraf Fadel Moh'd, MD, JBA, ArBA, Specialist of Cardiac Anaesthesia, Queen
Alia Heart Institute, King Hussein Medical Centre, Royal Medical Services of Jordanian
Armed Forces.
Salah AL-Tarabsheh, MD, MFRCSI, Consultant Cardiac Surgeon, Queen Alia
Heart Institute, KHMC, Royal Medical Services of Jordanian Armed Forces .
Razi Abuanzeh, MD, MRCS, FRCS-CTh, Consultant Cardiac Surgeon, Queen Alia
Heart Institute, KHMC, Royal Medical Services of Jordanian Armed Forces.
Yanal F. Al-Naser ,MD, AFRCSI, MRCS, Senior Cardiac Surgeon, Queen Alia
Heart Institute, KHMC, Royal Medical Services of Jordanian Armed Forces .
Haitham Altaani, MBBS, FACS, Consultant Cardiac Surgeon, Queen Alia Heart
Institute, KHMC, Royal Medical Services of Jordanian Armed Forces.
Omar Malkawi , CP, Chief of Clinical Perfusionist, Queen Alia Heart Institute, King
Hussein Medical Centre, Royal Medical Services of Jordanian Armed Forces.
Zaki Mohammad Quaiser ,CCP, Senior Certified Clinical Perfusionist, Queen Alia
Heart Institute , KHMC , Royal Medical Services of Jordanian Armed Forces .
Osama Mohammad Alserhan, CP, Senior Clinical Perfusionist, Queen Alia Heart
Institute, King Hussein Medical Centre, Royal Medical Services of Jordanian Armed
Forces.
Saker M. AL-Ma'ayeh, MD, Specialist of Cardiac and General Surgery, Royal
Medical Services of Jordanian Armed Forces .Amman. Jordan.
Aymen Mayta'h, CP, Senior Clinical Perfusionist, Queen Alia Heart Institute, King
Hussein Medical Centre, Royal Medical Services of Jordanian Armed Forces.

VIII
 Preface
There is no doubt that the separation point in the development
of cardiac surgery was in the development of Cardiopulmonary
Bypass Machine. Due to this Machine the heart surgeries became
safer, and some more complex defects could be done.
The correct use of the cardiopulmonary bypass machine is based
on the understanding of a lot of knowledge and related
disciplines, such as anatomy, physiology, pharmacology, principles
of cardiopulmonary bypass, and various surgical interventions,
also on clinical training on this device in the operating theaters.

This book is designed to provide an easily readable source, with

avoidance of the excessive expansion in subjects that are of less
importance for the perfusionist, and without emphasis on the
history and studies details .
I have made every effort to provide accurate information "based
on my experience in this specialty", but there are some areas of
debate, and rapid developments in science and renewing
guidelines, that change the accepted standard in this field.

I hope that newcomers to this specialty will find this book useful,
and the experienced perfusionist will find it as a useful guidance.
It can also be helpful for cardiac anesthetists, surgeons, and
cardiologist.
I would like to thank everyone who helped in the preparation of
this book, whose shared their experience and knowledge with us.

Mohammad Barham . CCP.

IX
X
 Contents
(a)
..I
(b) Copyright IV
(c) Author ......V
(d) Dedication .VII
(e) Contributors and Reviewers ..VIII
(f) Preface .....IX
(g) Contents ......XI
(h) Tables ......XVII
1. Anatomy and Physiology of the Heart
Whats the Heart .................................................................................... 3
Heart Muscle .......................................................................................... 5
The Function of the Heart ...................................................................... 7
Heart Wall .............................................................................................. 9
Blood Supply of the Heart....................................................................... 11
Parts of Heart .......................................................................................... 12
Cardiac Cycle ......................................................................................... 16
Cardiac Physiology ................................................................................ 23
2. Blood
Blood ....................................................................................................... 29
Functions of Blood .................................................................................. 29
Components of Blood ............................................................................ 29
Plasma ..................................................................................................... 30
Blood Cells ............................................................................................. 32
Blood Groups ......................................................................................... 38
3. Human Blood Circulation
Human Blood Circulation ...................................................................... 43
Types of Vessels ..................................................................................... 45
Major Systemic Arteries ........................................................................ 48
Major Systemic Veins ............................................................................ 49
Distribution of Blood in the Blood Vessels ........................................... 50
Transmission Fluid at Capillaries ........................................................... 51
4. Extra Corporeal Circulation
Cardiopulmonary bypass (CPB)
Cardiopulmonary bypass machine ..................................... 55
XI
Cardiopulmonary Bypass Circuit ............................................................. 57
Blood pump ............................................................................................. 58
Suckers and vents.................................................................................... 65
Tubing .................................................................................... 68
Advantage and disadvantage of PVC and silicone tubing ............................ 69
Size of Tubing ......................................................................................... 70
Maximum flow and drainage through the various sizes of tubing .......... 71
Sizes of Arterial Pump (Raceway) Tube According Flow Rate ............. 71
Arterial and Venous Line Size ............................................................... 72
Tube priming Volume Per Meter ............................................................ 72
Tube Priming Volume Per Round ........................................................... 73
Cannulas................................................................................. 75
Arterial cannula ................................................................................... 78
Dispersion Stream Arterial Cannula ....................................................... 80
Arterial cannula size as flow required .................................................... 81
Complications of aortic root Cannulation .............................................. 82
Complications of peripheral cannulation ................................................ 82
Causes of aortic cannula high pressures ................................................. 82
Venous cannula .................................................................................... 84
Venous Cannula Size ............................................................................. 85
Complications of venous Cannulation ................................................... 86
Causes of poor venous return during CPB ............................................. 87
Cardioplegia Cannulae ......................................................................... 88
Retrograde Cannulae .............................................................................. 90
Antegrade Aortic Root Cannulae ........................................................... 91
Antegrade Coronary Perfusion Cannulae .............................................. 92
Cardioplegia Adapters ............................................................................ 94
Oxygenators ........................................................................... 95
The Ideal oxygenator .............................................................................. 95
Main functions of oxygenator ................................................................. 95
Type of oxygenator ................................................................................. 96
Blood Flow Path through Oxygenators .................................................. 109
Principles of Membrane oxygenator ....................................................... 112
Size of Oxygenators ............................................................................... 114
Cardiopulmonary Bypass Filters......................................... 118
Filters used within the CPB circuit and function .................................... 118
Blood Filters ........................................................................................... 119
Filter Types ............................................................................................. 119
Arterial Line Filters ................................................................................. 120
White Cell Filters (leukocyte-depleting) ................................................ 122
Hemoconcentrators Hemofilter ............................................................... 123
XII
Modified Ultrafiltration(MUF) .............................................................. 126
Intraoperative Cell Sever......................................................................... 128
Surface Coatings.................................................................... 132
Heparin Coating ..................................................................................... 132
Phosphorylcholine Coating ..................................................................... 133
Synthetic Polymer Coatings .................................................................... 133
Titanium nitride (TiN) coating ............................................................... 133
5. Conduct of Cardiopulmonary bypass
Safety checks and setup of the circuit ................................ 136
Check up the heartlung machine and accessories ............................ 136
Connection checks .................................................................................. 136
Pump head checks ................................................................................... 136
Electrical safety device checks ............................................................... 137
Setup of disposable heart lung equipment .......................................... 137
Set up time .............................................................................................. 137
Set up shelf life ....................................................................................... 137
The Hard shell Venous Reservoir setup .................................................. 138
The oxygenator (membrane) setup ......................................................... 139
Arterial line filters setup if demand ....................................................... 140
The cardioplegia system setup if demand .............................................. 141
The centrifugal pump setup if demand .................................................. 141
Administration of Priming Fluids .................................... 142
Crystalloids as priming solution ......................................................... 144
Dextrose ................................................................................................. 144
Balanced crystalloid fluids ...................................................................... 145
Mannitol ................................................................................................. 146
Colloids as priming solution ................................................................. 147
Albumin .................................................................................................. 148
Dextrans .................................................................................................. 149
Gelatins .................................................................................................. 150
Hydroxyethyl starch ............................................................................... 151
Characteristics of commonly available colloids ..................................... 154
Select the Correct Priming Fluids ...................................................... 155
Composition of commonly available priming fluids .............................. 156
The dose of the substances that commonly additive to priming ............. 157
Priming Influence in Hemostasis ........................................................ 158
Priming Steps for Cardiopulmonary Bypass Circuits ...... 159
Filling the Reservoir ................................................................................ 159
Recirculation .......................................................................................... 159
Prime the A/V Loop ............................................................................... 160
Pre-warm the Priming Fluid .................................................................... 161
XIII
Priming cardioplegia if demand .............................................................. 161
Priming centrifugal pump if demand ...................................................... 162
Occlusions Setting ................................................................. 163
Occlusion of the arterial pump if a roller pump is used .......................... 163
Occlusion of the suction pumps ............................................................. 164
Anticoagulants for Cardiopulmonary Bypass .................... 166
Coagulation ............................................................................................ 166
Heparin .................................................................................................... 167
Mechanism of Heparin Action ............................................................... 168
Heparin Dosing ...................................................................................... 169
Side Effects of Heparin .......................................................................... 170
Perioperative Abnormal Coagulation ..................................................... 171
Monitoring the Activity of Heparin ....................................................... 172
Anticoagulation Management in CPB .................................................... 174
Heparin Resistance .................................................................................. 175
Reversal of Anticoagulation ................................................................. 176
Protamine ............................................................................................... 176
Calculation of Protamine Dose ............................................................... 177
Side Effects of Protamine ....................................................................... 178
Protamine Reactions ............................................................................... 178
Normal Coagulation Values .................................................................... 179
6. Conduct of Perfusion
Pre-Bypass Management ........................................................................ 189
Normal Range and Blood Products Information .................................... 181
Pre-Bypass checklist .............................................................................. 190
The CBP Communication Team ............................................................. 192
Starting CPB .......................................................................................... 194
Weaning from CPB and pump off ......................................................... 197
7. Perfusion Flow and Patient Pressure
Perfusion Flow and Patient Pressure ...................................................... 201
Systemic Blood Pressure ........................................................................ 204
Fluid Movements in the Capillary .......................................................... 206
Basic Principles of Perfusion Flow .......................................................... 207
Conduct of Perfusion Pressure ............................................................... 209
Pulsatile flow ........................................................................................... 211
Significance of the Pulsatile Flow ............................................................ 213
Pulsatile flow perfusion pumps............................................................... 214
Arterial-venous Shunting ........................................................................ 218

XIV
8. Pediatric Cardiopulmonary Techniques
Pediatric Cardiopulmonary bypass Techniques ...................222
Differences Between Pediatric And Adults .................................................. 223
Differences in Tube Circuits Size .................................................................... 223
Differences in Cannulation .............................................................................. 224
Major Differences Between Adult and Pediatric ............................................. 227
Acceptable hemodilution During CPB.....................................228
Advantages and Disadvantages of hemodilution ............................................. 229
Hemodilution and Oxygen Carrying Capacity ................................................. 230
Oxyhemoglobin Dissociation Curve ................................................................. 231
Hemodilution Level Management ................................................................... 232
Optimal Hematocrit After Bypass..................................................................... 234
Vacuum Assisted Venous Drainage Technique .....................235
Causes of used Assisted Venous Drainage ....................................................... 236
Advantages of VAVD ...................................................................................... 236
Assisted Venous Return Techniques................................................................. 237
Vacuum Assisted Venous Drainage Management ........................................... 239
Disadvantages of VAVD .................................................................................. 239
Avoiding Blood Transfusion for pediatric on CBP ................240
Advantage of Vacuum-Assisted Drainage in set up ......................................... 241
Specifications of the Circuit ............................................................................. 242
Advantage of Smallest and Short Tubing ........................................................ 242
Disadvantage of Short Tubing ......................................................................... 243
Characteristics of pediatric Heart-Lung Machine ............................................ 244
Position of the Head pump ............................................................................... 244
Position of the Heart-Lung Machine ................................................................ 245
Hypothermia and hypothermic circulatory arrest ................246
Heat Transfer During Cardiopulmonary Bypass .............................................. 249
Temperature Monitoring .................................................................................. 250
Advantages Hypothermia ................................................................................. 251
Disadvantages of hypothermia .......................................................................... 257
Cerebral Blood Flow ..................................................................258
Basic of Cerebral Blood Flow .......................................................................... 259
Cerebral Hemodynamics ................................................................................... 260
Control of Cerebral Blood Flow ....................................................................... 261
Calculating the Adequate Amount of Cerebral Blood Flow ............................. 270
Modified Ultrafiltration(MUF) ................................................271
Technique of MUF ........................................................................................... 272
Advantages of Modified Ultrafiltration ............................................................ 273
Disadvantages of Modified Ultrafiltration ....................................................... 274

9. Myocardial protection
Maintain the Myocardial Function .................................................................... 278
XV
Cardioplegia ..................................................................................................... 280
Types of Cardioplegia ....................................................................................... 281
Delivery Sites for the Cardioplegia ................................................................... 283
Cardioplegia Flow Rates and Pressures ............................................................ 285
Initial Dosages of Cardioplegic Solution .......................................................... 286
Cardioplegia Delivery Systems ........................................................................ 286
Warm Blood Reperfusion (Hot Shot) .............................................................. 286
Side Effect of Cardioplegia Solutions .............................................................. 286
10. Mechanical circulatory support
Intra-aortic balloon .....................................................................290
Intra-Aortic Balloon Counterpulsation ............................................................. 291
Primary Effect of IABP .................................................................................... 292
Secondary Effects of IABP ............................................................................... 292
Effects on other systems .................................................................................. 293
Indications for use of Intra-Aortic Balloon ...................................................... 293
Contraindications for use of Intra-Aortic Balloon ............................................ 294
Complications of Intra-Aortic Balloon ............................................................. 295
Insertion of Intra-Aortic Balloon ..................................................................... 296
Augmentation of Intra-Aortic Balloon .............................................................. 298
Trigger of IAPB ................................................................................................ 299
Balloon Pressure Waveform ............................................................................. 299
Timing of IAPB ................................................................................................ 301
Abnormal Balloon Pressure Waveforms........................................................... 307
Causes of poor diastolic augmentation ............................................................ 313
Causes of poor afterload reduction .................................................................. 313
Nursing Care .................................................................................................... 313
Troubleshooting ............................................................................................... 314
Weaning of IAPB .............................................................................................. 316
Removal of IAPB .............................................................................................. 316
Extracorporeal membrane oxygenation .................................317
Types of ECMO ............................................................................................... 320
Indications and contra indications of ECMO ................................................... 326
Priming of ECMO ............................................................................................. 329
Cannulation of ECMO ...................................................................................... 331
Problems during the use of ECMO .................................................................. 333
Ventricular assist device (VAD) ................................................................. 334
Components of VAD ........................................................................................ 336
VAD Pump Types ............................................................................................ 337
Clinical indications for VADs .......................................................................... 340
Complications of VAD .................................................................................... 341
Most Common Types of VAD and Its Characteristics ..................................... 342
(i) Abbreviations ................................................................ 344
(j) References ...................................................................... 350
(k)
.............................................................. 361
XVI
 Tables
Table 1: Advantage and Disadvantage for Roller and Centrifugal Pump ........................................... 61
Table 2: Some Types of Rotary Pumps ................................................................................. 64
Table 3: Advantage and disadvantage of PVC and silicone tubing ..................................... 69
Table 4: Max flow and drainage through the various sizes of tubing .................................. 71
Table 5: Size of Arterial Pump Tube According to Flow Rate ............................................ 71
Table 6: Arterial and Venous Line Size as patients weight ................................................. 72
Table 7: Tube Priming Volume Per Meter ............................................................................. 72
Table 8: Tube Priming Volume Per Round ........................................................................... 73
Table 9: Blood flow rate Using the BSA ................................................................................ 76
Table 10: Pump Flow Rates as Patient weight (Kg) .............................................................. 76
Table 11: Some commonly used cannulation sites ................................................................. 77
Table 12: Arterial cannula size as flow required ................................................................... 81
Table 13: Venous Cannula size Dependent of Patient Weight .............................................. 85
Table 14: Neonate Oxygenator ............................................................................................... 114
Table 15: Pediatric Oxygenator .............................................................................................. 115
Table 16: Small Adult Oxygenator .......................................................................................... 116
Table 17: Adult Oxygenator ................................................................................................... 117
Table 18: Filters used within the CPB circuit and their function ........................................ 118
Table 19: Most Common Types of Arterial line Filters ........................................................ 121
Table 20: Most Commonly Types of Hemoconcentrators Filters ........................................ 125
Table 21: Most Common Types of Surface Coting ................................................................ 133
Table 22 : Characteristics of commonly available colloids .................................................... 154
Table 23: Composition of Commonly Available Priming Fluids .......................................... 156
The dose of the substances that commonly additive to priming ........................................... 157
Table 24: Normal Coagulation Values ................................................................................... 179
Table 25: Normal Blood Gas on Cardio Pulmonary Bypass ................................................. 189
Table 26: Normal Electrolytes ................................................................................................. 189
Table 27: Blood Products Information ................................................................................... 190
Table 28: Patient Weight and the Average of Body Surface Area ........................................ 185
Table 29: Patients Blood Volume based on Weight ............................................................. 186
Table 30: Monitoring Components of the CPB and Its Function ........................................ 188
Table 31: Safety Concerns During CPB ................................................................................ 196
Table 32: Blood Flow Rate Using the BSA ............................................................................ 207
Table 33: Minimum Blood Flow Depending of Patient Temperature .................................. 208
Table 34: Venous Cannula Size with Assisted Venous Drainage ......................................... 226
Table 35: Differences Between Adult and Pediatric CPB .................................................... 227
Table 36: The Oxyhemoglobin Dissociation Curve ............................................................... 231
Table 37: Minimum Blood Flow Depending of Patient Temperature .................................. 252
Table 38: Environments of Most Common Procedures......................................................... 254
Table 39: Arrest Period as the Patient Temperature ............................................................ 255
Table 40: Effect of temperature on cerebral metabolic rate & safe circulatory arrest duration ............ 255
Table 41: Basic of Cerebral Blood Flow ................................................................................ 259
Table 42: The Directed Percentage of Blood Flow to Organs from Cardiac Output .......... 270
Table 43: Cerebral Blood Flow Depending of Patient Temperature .................................... 270
Table 44: Intra-Aortic Balloon Sizes ...................................................................................... 296
Table 45 : ECMO Cannulation Site ....................................................................................... 331
Table 46: Most Common Types of VAD and Its Characteristics .......................................... 342

XVII
XVIII
1
2
 Anatomy and Physiology of the Heart
Whats the Heart
The Heart is really a muscle. And its about your fist size.
It's located in the middle of the thoracic cavity, behind sternum a
little to the left of the mediastinum, above the diaphragm, and
lungs are located on either side. View Figure 1 :1 . Apex of the heart
at 5th intercostal space . View Figure 1 :2 .

3
4
 Heart Muscle
The heart generates power and electromagnetic energy about
60 to 1000 times more than the brain, it the most powerful organ
in your body.
When you were in the womb, your heart was formed first,
before your brain. Your heart beats about 100,000 times a day,
40 million times a year, and if its connection to your brain were
severed, it would keep right on beating . (Dr. Bradley Nelson. The
Emotion Code, 2007) .

The heart muscle is different from all muscles in your

body(in your arms, in your legs, in your internal organs) View
Figure 1:2 . The heart muscle is special because of what it does.
The walls of the heart are made of a unique type of muscle called
cardiac muscle. Cardiac muscle cells are arranged in a network
that allows the heart to contract and relax rhythmically and
involuntarily without becoming fatigued.

5
 The myocardium consists of numerous layers of wrapping
muscle fibers. That wrap around the chambers ,and covers the
heart valves and tendons . The atrial myocardium is physically
separate from the ventricular myocardium , this isolation is vital
for the coordination of cardiac contractions. Each cardiac muscle
cell is wrapped in a strong elastic sheath, and adjacent cells are
tied together by struts. View Figure1:3.

6
 The Function of the Heart
Your heart is an organ that pumps blood around your body
via the circulatory system. The blood provides your body with
oxygen and nutrients, and removes the carbon dioxide and
metabolic waste product. The right side of your heart receives
blood from the body and pumps it to the lungs. The left side of
the heart receives blood from the lungs and pumps it out to the
body.
New research shows that your heart is much more than a
mere pump. In the 1970s, scientists learned that the heart has an
elaborate nervous system. The fact is, we all have two brains.
Much to these scientists surprise, they discovered that the brains
in our heads are obeying messages sent by the brains in our
hearts.. (Dr. Bradley Nelson. The Emotion Code, 2007) .
After the development of the heart transplantation from
person to another. Many considerable evidence are appeared that
the heart contains memories and feelings. A large number of
heart transplant recipients have demonstrated a change in the
type of food and drink that their preferences, as well as musical
preferences, handwriting changes, and some memories that seem
own for the person who donated the heart.

Your heart has its own unique intelligence. It can think,

feel and remember. Here, I would like to point out the scientific
miracles in the Holy Quran. The Quran spoke about that before
more than one thousand and four hundred years in the saying of
Allah
And surely, We have created many of the jinns and mankind for
Hell . They have hearts wherewith they understand not, they
have eyes wherewith they see not, and they have ears wherewith
they hear not (the truth). They are like cattle, nay even more
astray; those! They are the heedless ones {Al-A'raf 179}.
7


.]171 : [

And in the saying of Allah Have they not travelled through the
land, and have they hearts wherewith to understand and ears
wherewith to hear? Verily, it is not the eyes that grow blind, but
it is the hearts which are in the breasts that grow blind
{Al-Hajj 46}

.]46 : [

And in the saying of Allah Will they not ponder the Quran?
Or are there locks upon their hearts? { Muhammad 46}

.] : [

8
 Heart Wall
The outer walls of the heart chambers consists of three tissue
layers:
1- Epicardium: is a relatively thin layer of tissue forms the
external surface of the heart, that consists of a covering
mesothelium and a thin underlying layer of loose connective
tissue that merges into the connective tissue sheaths of the
myocardium. The loose connective tissue supports the blood
vessels and nerves that supply the heart.
2- Myocardium: Myocardium is the muscular middle layer
of the wall of the heart . It is composed of multiple interlocking
layers of cardiac muscle fibers which allow the heart to contract.
Heart contraction is an autonomic (involuntary) function of the
peripheral nervous system .

3- Endocardium: The endocardium is the innermost layer of

the heart chambers. Its consists of a layer of endothelial cells and
an underlying layer of connective tissue. The endocardium
provides protection to the valves and heart chambers. View Figure1:4
Figure1:4

1
 Pericardium
The heart surrounds by pericardium. Pericardium: is a
double-walled sac of fibrous tissue surrounds the heart and the
roots of the great vessels. The pericardial sac has two coats, the
parietal pericardium (the outer coat) is tough and thickened,
loosely coats the heart, and the visceral pericardium or
epicardium (inner coat ) is double, with one layer closely
adherent to the heart and the other lining the inner surface of the
outer coat. The intervening space between these layers is filled
with a small amount of fluid acts as a lubricant to allow normal
heart movement within the chest ,this fluid is known as
pericardial fluid. View Figure1:5 .

Figure1:5

11
 Blood Supply of the Heart
The heart has its own self blood supply (coronary
circulation), the coronary arteries arising from the ascending
aorta, through coronary ostia (openings located in proximal
aorta above the aortic valves). There are two main coronary
arteries ,the left and right coronary arteries , that branch from the
ascending aorta.
The left main coronary artery (LM) supplies the left
atrium, interventricular septum, left ventricle and the anterior
wall of the right ventricle.
The right coronary artery (RCA) supplies the right atrium,
the right ventricle as well as the sinoatrial node.
The coronary arteries blood flow happens during diastolic
(ventricle relaxes) , blood flows from left and right coronary
arteries to smaller arteries and arterioles, to coronary
capillaries(exchange location, blood released oxygen and
nutrients vital and picked up carbon dioxide and waste
products).coronary blood flows into the venules and then
coronary veins. From here, most deoxygenated blood drains into
the coronary sinus, located on the posterior surface of the
heart, emptying into the right atrium. View Figure1:6 .

Figure1:6

11
 Parts of Heart
The heart is divided into four chambers . There are two
chambers on each side of the heart: upper left and right, and
lower left and right.
The two chambers on upper are called the Atriums.
The two chambers on the lower are called Ventricles. View
Figure1:7

The right side of the heart receives non-oxygenated blood

that is coming back from the body, and then pumps this blood out
to the lung . The superior vena cava collects non-oxygenated
blood coming from the tissues in the head, chest, and arms. The
inferior vena cava collects non-oxygenated blood coming from
the lower body organs. Non-oxygenated blood flows from the
right atrium into the right ventricle, and then out into the
pulmonary trunk- left and right pulmonary arteries-left and right
lungs for gas exchange.
The left side of the heart receives oxygenated blood from
the left and right lungs through the left and right pulmonary veins
in the left atrium. The left atrium pumps blood into the left
ventricle, left ventricle pumps this blood out through the aorta to
the body . View Figure1:8 .
12
 The dividing wall between the right and left sides of the
heart called the Septum. The septums job is to separate the left
side and the right side of the heart. The septum that separates the
right and left atria of the heart is called the atrial septum, whereas
the septum that separates the right and left ventricles of the heart
is called the ventricular septum . View Figure1:8 .
The atria and ventricles work as a team, the atria fill with
blood, then dump it into the ventricles. While the ventricles
pump blood out of the heart, the atria refill and get ready for the
next contraction.

There is four valves inside the heart. This valves normally

allows blood to flow through the heart in one direction only. The
valves determine the pathway of blood flow through the heart. A
heart valve opens or closes incumbent upon differential blood
pressure on each side.

13
 The Two Atrioventricular (AV) Valves , which are located
between atrias and ventricles and ensure one-way flow. The Left
AV valve is mitral valve (bicuspid valve), and the Right AV
valve is tricuspid valve.
The Two Semilunar (SL) Valves, are called semilunar
valves because of their half-moon shape, the aortic valve and
the pulmonary valve, which are in the arteries leaving the heart.
View Figure1:9.

Heart Valves open and closing passively according to

surrounding pressure gradients:
AV valves open
when pressure in atriums > pressure in ventricles.

Semilunar valves open

when pressure in ventricles > pressure in arteries.

14
llllllThey can all valves closed (Isovolumetric Contraction , or;
Isovolumetric Relaxation ) , but they are never open all together
(Two open/Two closed).k
The AV valves consist of leaflets or cusps, chordae
tendineae, and papillary muscles, that prevent them from opening
backwards.

The mitral valve and the aortic valve are in the left heart and
the tricuspid valve and the pulmonary valve are in the right heart.
View Figure1:10.

15
 Cardiac Cycle
Cardiac Cycle: is a period from the beginning of one heart
beat to the beginning of the next one (rhythmic pumping of the
heart chambers).
The cardiac cycle can be divided into two major stages:m
First Stage: Atrial Systole .
(Includes: Late diastole (Slow ventricular filling), and atrial systole)
Late diastole : When the pressure in the atriums is higher
than the pressure in ventricles both mitral and tricuspid valves
are forced to open, a small volume of blood flowing from
veins and passing the atria to fill the ventricles (Slow
ventricular filling: chambers are relaxed and ventricles fill
passively). Atrial systole begins as a response to an impulse
from the sino-atrial node (SA node) , that forces a small
amount of additional blood into ventricles(20-30 %) this will
slightly rise pressure inside ventricles.
Second stage: The Second stage is divided into two phases:
1- First phase: Ventricular contraction (Systole).

(Includes: Isovolumetric contraction, and ventricular ejection)

The depolarization spreads from the atrioventricular
node (AV node) to the septum and the walls of both ventricles
through the bundle of His and Purkinje fibers.
Isovolumetric contraction: at the beginning of ventricular
contraction the pressure inside the ventricles rises causing
closure of AV valves , but does not create enough pressure to
open semilunar valves, because the ventricular pressure is
16
lower than that in the aorta and the pulmonary artery.
Intraventricular pressure keep rising while the ventricles start
to contract and the all valves are still closed. The volume of
blood inside ventricle prior this period is called Preload. Wall
tension is created while ventricles work to overcome the
resistance or pressure in the arterial(aorta and pulmonary
artery) .This resistance in the arterial circulation and the
resultant left ventricle wall tension created during systole
called Afterload.
Ventricular Ejection: when the pressure in the ventricles
exceeds the pressure in the main arteries, the semilunar valves
open (aortic and pulmonary valves) , and blood is ejected into
both aorta and pulmonary artery.
2- Second phase: Ventricular relaxation (Diastole).

(Includes: Isovolumetric relaxation, and ventricles relaxation)

Isovolumetric Relaxation: At the end of ventricular
ejection, both ventricles begin to relax and pressure inside
them drops below systemic pressures, so semilunar valves
valves closed (The AV valves already closed, all valves closed).
Ventricle Relaxation (Diastole): During isovolumetric
relaxation the pressure inside ventricles drops below the
pressure inside the atria causing opening of AV valves
(Atrioventricular valves) and ventricular filling occurs (Blood
flows rapidly from the atria to the ventricles), and the cycle
begins again . View Figure1:11 and Figure1:12.

17
Figure1:11

18
Figure1:12

11
P wave = atrial depolarization.
QRS complex = ventricular depolarization and atrial repolarization.
T wave = ventricular repolarization. View Figure1:14 .
Figure1:14

Depolarization is the electrical excitation of the cell

membrane caused by the flow of ions across it.
Repolarization is the return of the cell membrane to its
resting state. View Figure 1:15.
Figure1:15

21
 The events of the cardiac cycle can be diagrammed on
pressure wave . During atrial systole A-V valves open and
pressure slightly increase, when ventricular pressure becomes
greater than the atrial pressure, the A-V valves close, creating
1st heart sound, after that when pressure in the left ventricle
exceeds the pressure within the aorta; the aortic valve opens
allowing blood to flow into the aorta, then pressure starts to
fall below the arterial pressure so semilunar (SL) valves close
,creating 2nd heart sound. The beginning of ventricular
diastole could be seen in the arterial pressure wave and called
the Dicrotic notch .When ventricular pressure decreases below
atrial pressure, A-V valves open, leading to left ventricular
filling and 3rd heart sound is heard . The pressure changes by
the cardiac cycle can be diagrammed on the arterial wave
form, arterial pressure can be monitored from a central aortic
line or a peripheral line. View Figure1:16.
Figure1:16

22
 Cardiac Physiology
Cardiac Output: The volume of blood ejected from the heart
over a one minute period , referred to in liters per minute.
Cardiac Output = Heart Rate X Stroke Volume.
Heart Rate = beats/min .

Normal cardiac output range:

0.8 1.3 L/min (neonate/infant).
1.3 3.0 L/min (child).
4 8 L/ min (adult). During exercise the cardiac output
might go up to about 20 L/min for fit adult , and up to 35
L/min for a world-class athlete .

Heart rate (Heart Pulse) is the speed of the heartbeat

measured by the number of beats of the heart per minute.
Normal heart rate range:
100 180 beats/min (neonate/infant)
70 110 beats/min (child).
60 100 beats/min (adult).

Stroke Volume: The amount of blood (mL) ejected by the

ventricle with every systolic contraction(beat).
Normal stroke volume range:
5 13 mL/beat (neonate/infant).
13 50 mL/beat (child).
60 100 mL/beat (adult).

23
 Stroke volume: difference between end-diastolic
volume (EDV), and end-systolic volume (ESV).
SV = EDV - ESV.
EDV (End Diastolic Volume) = The amount of blood in
the ventricle at the end of diastole.
ESV (End Systolic Volume) = The amount of blood in
ventricle at end of systole.

Stroke Volume is affected by preload, afterload, and

contractility:
Preload: Is the volume of blood in the ventricle at the end of
diastole.
Preload also refers to the amount of myocardial fiber stretch
at the end of diastole. The length of ventricular muscle fiber
determines the magnitude of contraction (SV) . The length of the
LV muscle fiber is dependent upon the left ventricular end
diastolic volume (LVEDV).In other words increase in left atrial
filling would increase in force of LV ventricle contraction. The
relationship between end-diastolic volume and end diastolic
pressure is dependent upon the compliance of the muscle wall.
Frank and Starling law is defined the relationship between
myocardial fiber length and force of contraction. In normal
compliance heart, large increases in volume create small
increases in pressure. This will happen in a not fully dilated
ventricle. When the ventricle becomes more fully dilated, smaller
increases in volume produce greater rises in pressure. In
decreased compliance of the ventricle(the stretch goes beyond
physiological limits "left ventricle failure"), a greater pressure is
generated with very little increase in volume. Increased
compliance of the ventricle allows for large changes in volume
with little rise in pressure. View Figure1:17.

24
 In clinical practice the preload estimated by the Left
Ventricular End Diastolic Pressure (LVEDP) ,which can
measured indirectly as the pulmonary artery wedge pressure
(PAWP).

LVEDP = 4 12 mmHg.
PAWP = 4 12 mmHg.
CVP = 3 11 mmHg.
Afterload :Is the resistance to ventricular ejection(the
resistance or pressure in the arterial system that the ventricle
must overcome to eject its blood volume). Afterload has an
inverse relationship to ventricular function. As resistance to
ejection increases, the force of contraction decreases, resulting in
a decreased stroke volume. As resistance to ejection increases, an
increase in myocardial oxygen consumption also occurs.
Right and left ventricular afterloads are measured
differently: Pulmonary Vascular Resistance (PVR) for the
right ventricle and Systemic Vascular Resistance (SVR)
for the left ventricle.
25
 Afterload affected by many things including volume of
blood ejected, the presence of ventricular outflow
obstructions, and the vascular resistance.

Contractility :The myocardiums intrinsic ability to contract

independently of the effects of preload or afterload.
Measured indirectly by Ejection Fraction.

Ejection Fraction (EF): is the percentage of the total amount of

blood in the left ventricle(end-diastolic volume) is ejected out of
the ventricles with each heartbeat.

EF = 60 70% .
EF = (SV / EDV) x 100.

Cardiac index: The volume of blood pumped by the heart (liters

per minute) divided by the body surface area (square meters).

Normal Cardiac index range:

4.0 5.0 L/min/m2 (neonate/infant).
3.0 4.5 L/min/m2 (child).
2.4 4 L/min/m2 (adult).

26
27
28
 Blood
Blood : is the red fluid that flowing in our blood
vessels, which composed of blood cells suspended in
blood plasma.
Functions of Blood
There are two main functions of blood: Transport
nutrients and oxygen to the cells ,and carry metabolic
waste products(CO2, urea , ammonia and other wastes)
away from those same cells. Blood also maintaining a
relatively constant body temperature and plays a role in
defending the body against disease.
Components of Blood
Blood is composed of two main components :
1- Plasma (55%): which constitutes of water 91%,
proteins 7%, and other 2% ( Fats, Glucose, Electrolytes,
Gases (O2, CO2), Chemical messengers,).
2- Blood cells(45%): which constitutes of red cells
99%, white cells and platelets 1%. Vi ew Figure2:1 .

21
 Plasma
Plasma is a yellowish watery solution ,that carries nutrients,
hormones, and proteins throughout the body.

Plasma functions: maintaining blood pressure and volume ,

supplying clotting agents and providing an immune response, and
exchange vital minerals such as sodium and potassium, maintain a
proper balance in the body.

Plasma components:
Plasma consists of about 91% water, 7% proteins, and 2% other:

1- Water:
plasma consists mostly of water, and this allows our blood to
flow freely in the blood vessels to transport materials
throughout the entire body. It acts as a solvent for important
proteins, nutrients, electrolytes, gases, and other.

2- Plasma Proteins:
A. Albumins are the most common proteins in the plasma. The
main function of albumins is to maintain the osmotic
balance between the blood and tissue fluids (colloid osmotic
pressure),and carries substances around the body.

B. Globulins are a variety of proteins, divided into three

groups: alpha, beta and gamma. Its main function is to
transport various substances in the blood. Gamma globulin
help the immune system to defend against infections and
diseases.

31
 Blood Cells
This category includes the solid particles of blood: Red
blood cells, white blood cells, and platelets.
Red Cells ( erythrocytes )(4.5- 5 million/cubic mm) are
relatively large microscopic cells without nuclei. They carry
oxygen and collect carbon dioxide by hemoglobin. Hemoglobin
is the protein molecule makes up 95% of a red cell. Normally
hemoglobin is 14 - 18 % in healthy adult males and 12 - 16 % in
females. Each red cell is made of about 280,000,000 hemoglobin
molecules.
Each hemoglobin molecule consists of two parts: The first
part a globin portion composed of 4 polypeptide chains (Globin
chains), and second part is central structure called Heme group
molecule (red dye gives red blood cells their color).
Heme group consists of four units, each unit containing an
atom of iron(Fe +2). Globin consists of four protein chains, two
of these chains are called (alpha) ,and the other two of these
chains called (beta). View Figure2:2.

32
 When the blood supply to the lungs each iron atom ( Heme
group) in hemoglobin molecule linked with oxygen molecule,
and as we knew that every molecule of hemoglobin containing
four atoms of iron, that mean it carries four oxygen molecules.
View Figure2:3 .

nnnnEvreyone of red blood cell containing nearly three hundred

million molecule hemoglobin, this means it carry about one
thousand and two hundred million oxygen molecule .

Carbon dioxide also binds to amino groups (-NH2) on the

polypeptide(globin) chains ,about 22% of them , but the most
amount (about 78%) of carbon dioxide is dissolve in the plasma
(68% of carbon dioxide combines with water as bicarbonate ions
" CO2 + H2O <- -> HCO3- + H+ " , and 10% dissolves in the
plasma as gas).

The red cells are produced continuously in our bone marrow

from stem cells at a rate of about 2-3 million cells per second,
and have a lifetime of about 120 days.

33
 The red blood cell( RBC) has a biconcave disk shape, with
diameter is 7.2 microns, thickness is 2.1 microns, and central
diameter is 0.8 microns. View Figure2:4.
The RBC has a flexible membrane, that allows these cells to
distort their shape and pass through tiny micro vessels, as small
as 2m.

The percentage of RBCs in the total blood volume is

hematocrit (Hct) , normally hematocrit is 40-54% in healthy
adult males and 38 47% in females.
Red blood cells are prepared (for transfusion to patients) from
whole blood by removing plasma, and can be stored from 21 to
42 days.

34
 White blood cells (Leukocytes) (5,000 - 10,000/cubic mm) are
cells of the immune system involved in defending the body
against both infectious disease and foreign materials. Leukocytes
are larger than RBCs (10- 30 m), however, they are less dense
according to their function, there are five different types of
leukocytes(Basophil, Eosinophil, Neutrophil, Monocyte, B and
T-cell lymphocytes), all leukocytes produced from a
multipotent cell in the bone marrow known as a hematopoietic
stem cell. They live for about 3 to 4 days in the average human
body. Leukocytes are found throughout the body, including the
blood and lymphatic system. View Figure2:5.

35
 Platelets( thrombocytes) (150,000- 350,000 /cubic mm) are
fragments of cytoplasm without nuclei , that produced in bone
marrow from stem cells . They have a lifespan of 9-10 days.
They are the smallest of blood elements (about 23 m in
diameter). Platelets work with coagulation factors at the site of
wounds to stop bleeding, by adhering to the walls of blood
vessels to plugging the rupture in the vascular wall. View Figure2:6.

When an injury causes a rupture in blood vessel wall ,

platelets are activated. They change shape from round to spiny,
stick to the broken vessel wall and each other, and begin to plug
the break. Platelets also can release coagulating chemicals which
interact with other blood proteins to form fibrin. Fibrin strands
form a net that entraps more platelets and blood cells, producing
a clot that plugs the break. Recent research has shown that
platelets also help fight infections by releasing proteins that kill
invading bacteria and some other microorganisms. In addition,
platelets stimulate the immune system.
An abnormality of the platelets is called a thrombocytopathy,
the decrease number of platelets is called (thrombocytopenia), the
decrease in function of platelets is called (thrombasthenia), and the
increase in the number of platelets called (thrombocytosis) .

36
 If the platelets count is too low, excessive bleeding can occur.
Otherwise, if the platelet count is too high, blood clots can form
thrombosis, which may obstruct blood vessels and lead to events
such as a myocardial infarction, cerebrovascular accident (CVA),
pulmonary embolism . Effective of platelets in clotting blood are
not equally throughout the entire day. The internal biological
clock in body causes the peak of platelet activation in the
morning. This explains the occurrence of strokes(CVA) and heart
attacks more common in the morning.

37
 Blood Groups
There are many of antigens (sequences of amino acid and
carbohydrates) on the surface of red blood cells, that form the
different types of a complete blood type. Blood type is one of the
many possible combinations of blood group antigens.
Over 400 different blood group antigens have been found,
usually only the ABO blood group system and the presence or
absence of the Rhesus D antigen (Rhesus factor or RH factor).
The ABO group is made up of A, B, AB, or O blood types,
and the Rh group is either positive or negative.
During blood transfusion, some antigens can trigger a
patient's immune system to attack the transfused blood, blood
typing and cross-matching should be doing carefully to ensure
safe blood transfusions.
The presence or absence of antigen A and B on the surface of
red blood cells, is divided the blood to four major groups:
1- Group A has only the A antigen on red cells
(and B antibody in the plasma).
2- Group B has only the B antigen on red cells
(and A antibody in the plasma).
3- Group AB has both A and B antigens on red cells
(but neither A nor B antibody in the plasma).
4- Group O has neither A nor B antigens on red cells
(but both A and B antibody are in the plasma) Figure2:7.

38
 In addition to the A and B antigens, there is a third antigen
called the Rh factor, which can be either present (+) or absent ( ).
View Figure2:8.

In general, Rh negative blood is given to Rh-negative

patients, and Rh positive or Rh negative blood can be given to
Rh positive patients .
Blood Type O negative is the universal donor for red cell.
Blood Type AB positive is the universal donor for plasma.

31
41
41
42
 Human Blood Circulation
Blood Circulation: is the movement of the blood through the
heart and around the body.
The circulation takes about 20 seconds to pump blood to
every cell in your body.
Your body needs this steady supply of blood in order to
obtain the required nutrition, which is necessary for body's health
and growth. Your body also needs the blood supply to get rid of
wastes, which can seriously harm health if stays in the your body.
The left side of your heart sends the blood to the body
(Systemic circulation).
This blood holds plenty of oxygen which is necessary for the
cells to stay alive. Your body takes the oxygen from blood to
uses it in cells. Inside cells multiple chemical reactions occurs
with using oxygen and nutrients to produce energy, and thereby
produce metabolic waste products and carbon dioxide, thus
making needs to get rid of the carbon dioxide and other waste by
dumping back into the blood to be carried away from the cells.
The blood has done the first part of its job by delivering oxygen
and nutrients to cells, and now its time for the second part of
blood job ,which is carrying wastes away from cells to the
excretory systems of the body . Normally, about 20% of the total
blood pumped by left heart "each time" will enter the kidneys to
undergo filtration, where waste products is removal from the
blood to keep your body healthy, and then the blood goes back to
right heart.
Systemic circulation: Left heart Aorta Arteries Arterioles
Capillaries Venules Veins Vena cava Right heart .
The right side of the heart receives non- oxygenated
blood from the body and pumps it to the lungs (Pulmonary
circulation),where it picks up oxygen and gets rid of carbon
dioxide. Carbon dioxide leaves the blood by getting breathed out
through the lungs, and oxygen gets into the blood from the air we
breathed in.
43
 Now the blood has got the oxygen it needs to go back to the
left side of the heart and start again. The systemic circulation and
pulmonary circulation happens in less than half a minute.
Pulmonary circulation: Right heart Pulmonary arteries
Lungs Pulmonary vein Left heart .
The blood vessels that carry out blood(Oxygenated blood
with exception of the pulmonary artery, it holding deoxygenated
blood) away from the heart are called arteries. The blood
vessels that carry blood (Deoxygenated blood with exception of
the pulmonary veins, they holding oxygenated blood) back to
the heart are called veins. There are many veins and arteries all
throughout your body. View Figure3:1.

44
 Types of Vessels
The cardiovascular system is a complex set of vessels, from
which the blood circulates (pumped by the heart) through the
body.

Left heart Aorta Arteries Arterioles

Capillaries Venules Veins Vena cava Right heart.

Types of Vessels:
1. Arteries.

2. Arterioles.

3. Capillaries.

4. Venules.

5. Veins.

The largest artery leaving the heart is the aorta. when the
aorta moved away from the heart is divided into smaller arteries,
the distal arteries become smaller , and called arterioles.
Arterioles eventually become capillaries, which are very thin
and branching .
Capillaries are really more like a network that are the
exchanged place between the blood and cells. The blood gives up
its carbon dioxide and waste products, and takes on oxygen and
nutrients . In capillary beds the white blood cells can be able to
leave the blood to defend the body against harmful invaders. The
capillaries begin to thicken and merge, to become venules.
Venules eventually become veins and head back to the heart.
Veins do not have many elastic fibers as arteries. Veins contain
valves, that prevent the blood from flowing back to the legs
under the influence of gravity. View Figure3:2.
45
46
 The Microcirculation: The confluence of the distal arterial
(arterioles) and venous territories (venules) constitute what is
known as the microcirculation,, which composed of arterioles,
capillaries and venules.
Arteries and veins have layers of smooth muscle surrounding
them. Arteries have a much thicker layer, and many more elastic
fibers. Arteries have the ability of elasticity, in systole they can
expand to accept a volume of blood, then contract and back to
their original size after the pressure is released in diastole.
The cardiovascular system are coated by three basic tissue
layers,These layers are:
A- Tunica interna: the innermost layer of the vessel,
consisting of endothelial cells, which the primary function
is to avoid contact of blood with endothelial thrombogenic
substances.
B- Tunica media: the middle layer, it consisting of elastic
tissue and smooth muscle cells, which controls the caliber
of the vessel.
C- Tunica externa: the outermost layer of the vessel,
primarily composed of connective tissue. It also contains
nerves that supply the vessel ,and nutrient capillaries. View
Figure3:3.

47
Figure3:4. Major systemic arteries ( deliver oxygenated blood
throughout the body)

48
Figure3:5. The major systemic veins of the body.

41
Distribution of Blood in the Blood Vessels

Distribution of blood volume in vessels is unevenly. About

65% of systemic circulation blood found in the vein ,30% in
arteries, and 5% in capillaries.View Figure3:6 .

51
 Transmission of Fluid at Capillaries
Processes that move fluids across capillary walls:
1- Diffusion. 2- Filtration.
3- Hydrostatic pressure (CHP). 4- Reabsorption.
Small molecules(e.g. gases, lipids, ions) can diffuse directly
through the membranes of the endothelial cells of the capillary
wall .But ,the mass movement of fluids into and out of capillary
beds requires more efficient mechanism than mere diffusion.
There is two pressure-driven mechanisms interact to drive these
movement, the hydrostatic pressure and osmotic pressure.
Forces acting across capillary walls:
1. Capillary hydrostatic pressure (CHP)= 35 mmHg at arterioles
(arterial end) of a capillary and 18 mmHg at venules (venous
end) of the capillary.
2. Blood Colloid osmotic pressure (BCOP) = 25 mmHg.
3. Interstitial fluid colloid osmotic pressure (ICOP) = 1 mmHg .
4. Interstitial fluid hydrostatic pressure (IHP) = 0 mmHg.
Capillary Hydrostatic pressure: is the pressure that the fluid
exerts against the capillary wall.
Osmotic pressure: is the pressure required to prevent the
movement of water across a semipermeable membrane via
osmosis(protein cells helps ensure that fluids pass in and out of
the capillaries at the proper rate).
Net filtration pressure: is the difference between the capillary
hydrostatic pressure and the osmotic pressure ,which determines
the movement of fluid between capillaries and interstitial fluid.
Capillary hydrostatic pressure and colloid osmotic pressure are
helps in regulate the movement of fluid between capillaries and the
interstitial , capillary hydrostatic pressure is highest (35 mmHg) at
the arterial end (Arterioles) of the capillary, and lowest (18 mmHg)
at the venous end(Venules). Capillary hydrostatic pressure created
51
due to the pumping action of heart. Capillary osmotic pressure is
steady along the capillary (25 mmHg) ,it created by the large
molecular weight of protein cells.
The difference between the capillary hydrostatic pressure
and the colloid osmotic pressure(CHP-COP = Net filtration pressure)
determines the movement of fluid between capillaries and
interstitial fluid .
If the capillary hydrostatic pressure is greater than osmotic
pressure the fluid will leave the capillary . If the capillary
hydrostatic pressure is less than that of osmotic pressure fluid
will enter into the capillary. At the arterial end of a capillary the
blood pressure on the average is about 35 mm, which is higher
than the pressure of the tissue fluid outside the capillaries, this
helps to force fluid out of the capillaries (Filtration) , the fluid
moves out of the capillary with net filtration pressure 10(35-25)
mmHg. At venous end of the capillary , the capillary hydrostatic
pressure decreases to about 18 mm Hg , as result of increased
cross-sectional area and frictional resistance of the capillaries,
which lead to draw the fluid to the capillaries (Reabsorption)
with net filtration pressure -7(18-25) mmHg.View Figure3:7 .

52
53
54
 Extra Corporeal Circulation
Cardiopulmonary bypass (CPB)
Cardiopulmonary bypass (CPB) is a technique allows blood
to bypass the heart and lungs, and takes over the function of the
heart and lungs temporarily during surgery, to maintaining the
circulation of blood and the oxygen content of the body.
The Cardiopulmonary bypass machine also known as
a heartlung machine(HLM) or "the pump". Cardiopulmonary
bypass pumps are operated by perfusionists.
The Cardiopulmonary bypass consists generally of, the
CPB machine and circuit comprises of plastic tubing, cannulas,
and oxygenator . The CPB is designed to maintain systemic
blood flow, oxygenation, and temperature regulation during
surgery. Venous blood is drained by gravity into the reservoir by
cannula placed in the right atrium or (SVC & IVC ),then pumped
through the oxygenator(oxygenation of blood, remove carbon
dioxide and cool/rewarm blood ) and returned into the patients
arterial system by cannula in the ascending aorta. View Figure 4:1 .

55
 Cardiopulmonary Bypass Machine
The typical cardiopulmonary bypass machine consists of a
series of blood pumps that provide cardiopulmonary support
through disposable tubing, central control monitor , data
management system , and emergency battery . View Figure 4:2 .

56
 Cardiopulmonary Bypass Circuit
The cardiopulmonary bypass circuit is a device designed to
divert a patients blood circulation around the heart to maintain
bloodless field during the surgical repair.

The typical cardiopulmonary bypass circuit includes many

disposable components oxygenator, blood collection reservoir, heat
exchanger, tubing, arterial filter and bubble trap, and various
suction systems can be used to return blood from the surgical field,
cardiac chambers, and/or the aorta, directly back into the
cardiotomy reservoir. View Figure 4:3 .

57
 Blood Pumps
Roller Pumps
These are the most widely used type of pump. These pumps
consist of rollers (usually two) positioned on the end of a rotating
arm. Forward flow is induced by the rollers compressing tubing
mounted in a U-shaped raceway. The flow rate is dependent on
the diameter of the tubing, the diameter of the raceway and the
rotation rate of the rollers.
The occlusive nature of the mechanism induces negative
pressures at the inlet side, rendering this type of mechanism
appropriate for both arterial blood pumping systems and suction
pumping . View Figure 4:4 .

Figure 4:4 .Sorin group S5 roller pump . The two rollers are linked on common hub. The
rollers is able to rotation in either a clockwise or counter-clockwise direction. Each roller
operates as a clamp when in contact with the tubing, by rotating the roller over the tubing.
58
 Rotary pumps
Rotary pumps have two basic types, centrifugal
and axial pumps.
Centrifugal Pump
The centrifugal pumps consists of vane less rotor cones,
capable of spinning at high velocity (up to 4,000 or 5,500 RPM),
mounted in a clear plastic housing, causing circular motion (
constrained vortex) of the blood and generating flow and
pressure by centrifugal force. The cones spin by means of an
indirect magnetic connection to a drive shaft on the centrifugal
pump console. Other commercially available centrifugal pumps
contain vanes rotators or impellers that increase pump efficiency,
thus allowing slightly lower rpm.
The centrifugal pump divided to two major types:
The first type consists of a nest of smooth plastic cones ,
contained within plastic housing. The second type consists of a
vanes impeller, inside the conical plastic housing. The cones or
impellers are rotated by coupled the base of the plastic housing
(magnetic coupling) to an electric motor ,rapidly rotated lead to
impart of kinetic energy to the blood, inducing forward flow.
View Figure 4:5.

51
 The centrifugal pump is non-occlusive, and flow is
dependent on the pressure change (Preload and Afterload)
created by the spinning cone within the pump. The flow rate is
affected by the aortic cannula size, tubing length, tubing
diameter, restrictions in the tubing, and changes in the
patient's systemic vascular resistance (SVR). The blood is
drive through the plastic housing by a pressure differential,
which results from the difference of the velocity (cm per sec) of
the narrow potion of the impeller cone (at the top) as compared
with the wider potion of the cone (at the bottom) creates a
pressure difference. It is also affected by the afterload . View Figure
4:6:1 .

When a centrifugal pump is used an electromagnetic flow

meter probe must be placed to the arterial line to determine
pump flow, it is placed often between the arterial line filter and
patient to accurately determine the flow rate.
If the centrifugal pumps become filled with air ,it will not
pump blood, because they relies on centrifugal force to generate
pressure. But a small bubbles can be easily transmitted into the
systemic circulation if they are present in the blood.

61
 Advantage and Disadvantage for Roller
and Centrifugal Pumps
Table 1: Advantage and Disadvantage for Roller
and Centrifugal Pump
Blood Advantage Disadvantage
pump
Non expensive disposable Blood trauma.
parts .

Simple to set up and prime. Possibility of circuit disruption

due to high presser.
Roller Pump

Simple flow rate microparticles from the inner wall

determination of tubing spallation .
(Rpm Stroke volume ).
Possibility to use with Possibility of massive air emboli.
different size patient .

The pulsatile flow Occlusion variability affecting

Possibility
Decreased blood trauma.
No Possibility of circuit
Centrifugal Pump
flow rate and blood trauma .
Contraindication for long-term
use because of tube wear and
blood trauma.
Expensive.
More complex.

disruption due to high

presser.
Less risk of massive air flow probe is necessary.
emboli .
Elimination of tubing Retrograde flow when pump
spallation. slows or stop and can draw air
into the arterial line from
cannulation site.

61
 The recent studies have confirmed that there is no
significant differences in the hemolysis, hematocrit values ,or
platelet counts in patients who were subjected to extracorporeal
bypass, whether the roller pump or the centrifugal pump was
used. Furthermore, extra cost, additional amount of the prime,
and the increasing complexity of the circuit. This led to the
common use of the centrifuge pump in the long-term support
only (e.g. ECMO, VAD), or in patients with heavy weights.

62
 Axial pump
The Axial blood pump is a new generation of rotary pump ,
it consists of axial or diagonal impeller driven by an electric
motor to generates an axial flow by rotating the blood internal
impeller. View Figure 4:6:2 .

Impeller is an important component in axial pump, and its

structure mostly determines the heart pump performance, thus a
marked improvements in impeller design ensures a high flow rate
and little blood damage. Axial pump motivated by electric motor
to provide high-speed rotation. In some generation both
continuous flow and pulsatile operation are possible (e.g. DP3
from Medos).
When comparing between centrifugal and axial pump design
theory, centrifugal pumps are capable of producing higher
pressures at lower flows, whereas axial pumps typically generate
higher flows at lower pressure rises. The priming volume of
axial pumps is smaller than that of centrifugal pumps, so it
usually utilized in pediatrics ECMO and ventricular assist device
(VAD) .Axial flow pumps operate at much higher rotational
speeds(up to 15,000 rpm), than centrifugal pumps (up to 5,500
rpm)to produce the desired head pressure and flow. In addition,
63
axial flow pumps have a lower energy consumption, which
allows lighter power supply components and eventually
implantable batteries. (See Table 2) .

Table 2: Some Types of Rotary Pumps

Centrifugal Flow Pumps
Name Speed Flow Pressure Prime Motor drive Surface
RPM LPM mmHg (Static) coating
Capiox 3000 0 -8 0 - 800 45 mL Mechanical X coating
(Terumo)
Delphin 3600 0.3 0 - 700 48 mL Mechanical X coating
(Sarns) 9.9
Biomedicus 4500 0 9.9 -300 - 999 Mechanical Carmeda
550
Rotaflow 5000 0 9.9 0 - 750 32 ml Magnetic Bioline
(MAQUET)
Centrimag 5500 0 9.9 0 - 600 31 ml Magnetic
(Levitronix)
PediVAS 5500 0 - 1.7 0 - 540 14 ml Magnetic
(Levitronix)
Bio-Pump 4500 0 - 1.5 0 - 900 48 mL Magnetic Carmeda
(Medtronic)
Axial Flow Pumps
Name Speed Flow Pressure Prime Motor Surface
RPM LPM mmHg (Static) drive coating
DP2 10000 0-8 0 - 600 17 ml Mechanical Rheoparin
(Medos)
DP3 10000 0-8 0 - 600 16 ml Mechanical Rheoparin
(Medos)
MicroMed 12500 0 - 10 0 - 100 Mechanical Polished
DeBakey titanium
VAD
Incor 7500 0-6 0 - 80 Magnetic Titanium &
(Berlin Heart) Carmeda
HeartMate ll 15000 0 - 10 0 - 300 7 ml Mechanical Textured
(Thoratec)

64
 Suckers and Vents
The pump suckers allow to salvaged the blood from the
operative field to be returned to the circuit via the reservoir .
The vent (sump) catheters are used for venting the left heart
during CPB surgery, by selecting an adequate sizes(from 8 Fr.
for neonates up to 20 Fr. for adults) , and length of the hole and
the tip model according to the site which dedicated to placing the
vent . All vents should be tested before use by briefly immersing
the tip of the vent in a pool of blood at the operative site to
confirm its suctioning effect. Avoid excessive negative pressures
is important, which can cause hemolysis.
This may be accomplished by use of a one-way negative
pressure relief valve in the vent line, or by inserted a small-gauge
needle in the vent line to relieve pressure.
The most common sites for placing dedicated vents (sump) are:
(A) The aortic root.
(B) The right superior pulmonary vein.
(C) The left ventricular apex.
(D) Pulmonary artery, the left atrium or the left ventricle.
View Figure 4:7

65
Sources of blood returning:
Normal sources of blood returning to the left heart include
bronchial ,cephalic and pulmonary veins.
Abnormal sources include an LSVC, PDA, systemic-to-
pulmonary shunt, septal defects, anomalous systemic
venous drainage, and aortic regurgitation.

There are a number of reasons for venting the heart

during CPB:
Prevent distension of the heart.
Reduce myocardial re-warming.
Improve surgical exposure.
Evacuate air from the cardiac chambers during the de-
airing phase of the procedure.
Create a dry surgical field, especially during the distal
coronary anastomosis phase of CABG surgery.

Complications of venting:
Damage to the LV wall due to excessive suction.
LV wall rupture if inadequately closed at the end of the
bypass period.
Sump may introduce air into the left heart and carries the
risk of systemic air embolism.

66
Complications of suctioning:
Hemolysis.
Fat globule formation.
Activation of coagulation and fibrinolysis
Platelet injury and loss.
Cellular aggregation.
Gaseous microemboli .
Bring the fat, bone, lipids, and other debris from the surgical
field that may aggravate the systemic inflammatory response
and microcirculatory dysfunction.

Note : Careful suctioning at the surgical field, and minimizing

flow rates of suctioned using largest suction tips possible, and good
occlusion can decrease blood damage.

67
 Tubing
The components of the CPB circuit are interconnected by a
series of tubes made of silicone rubber or PVC Poly(vinyl
chloride).

hhhPVC tubes are made up of polymer chains with carbon-

chloride (C-Cl) polar bonds.lj
PVC is a fairly rigid plastic, but plasticizers can be added to
make it more flexible.

Plasticizers are molecules that incorporated into the polymer

chains, to make them glide over each other more easily, thus
increasing the flexibility of the PVC. However, during
hypothermia the PVC tubing become more stiff and tends to
induce spallation. Spallation is, the release of plastic
microparticles from the inner wall of tubing, due to pump
compressions on tube.

There are other materials used to manufacture perfusion

tubing include latex rubber and silicone rubber. When use the
completely occluded head pump, latex rubber generates more
hemolysis than PVC. While silicone rubber produce less
hemolysis , but can release more particles than PVC.

Because of the durability (Resilience) of PVCs and

accepted hemolysis rates, PVC is the material most
commonly used for tubing. But the roller head pump is
exception to this, because the tubing at this site is constantly
compressed by the rollers ,that leads to the use of the silicone
tubing for this site to reduce blood hemolysis and to reduce
the load on the head pump .

68
 Note: the sterilization of the tubes is doing by ethylene
oxide gas and not use the pyrogenic (producing fever) methods
such as steam.

Table 3: Advantage and disadvantage of PVC and

silicone tubing
types Advantage Disadvantage
tubing
Clear. Stiffness during hypothermic
Resilience (memory): permits the More hemolysis than silicone.
tubing to resume its original shape
PVC

after compression) .

Thermal stability. Cannot be used for long-term

support within a roller pump.
Biocompatibility(nontoxic and
minimize inflammatory responses)

Less hemolysis. Not clear.

silicone

Biocompatibility. Not Resilience.

Softness for head pump (truer Lack of Thermal stability.

stroke volume ).

release more spallation than PVC.

Heparin-coated tubes give higher level of biocompatibility,

decreased inflammatory responses, and inhibits thrombin and
platelets activity. That permitted to reduction in the standard heparin
doses, and possibility of the use of tubes in the long-term support
such as ECMO.

61
 Size of Tubing
There is there numbers to describe the tube size:
1- Inside Diameter. for e.g. 1/8 inches
2- Outside Diameter. for e.g. 1/4 inches
3- Wall Thickness. for e.g. 1/16 inches
In upper example the tube size describe by write.
1/8 x 1/4 x 1/16 , or 1/8 x 1/16 .
View Figure 4:8 .

The size (Inside Diameter ) of tubing used at different points

in the circuit is determined by the pressure and rate of blood
flow that will be required through that region of the circuit, or
through a particular component of the circuit .

The perfusionist must define his custom pack tubing sizes

through his knowledge of the maximum acceptable flows and
maximum drainage through the various sizes of available tubing .

71
 The objective in defining custom tubing pack line sizes is to
achieve the smallest prime volume while ensuring adequate and
safe flow rates and pressures . View Table 4 & 5 & 6.

Table 4: Maximum flow and drainage through the

various sizes of tubing
Tubing size Max Flow Max gravity Max vacuum assisted
drainage drainage
Inch mL/min mL/min mL/min
<450 250-300 400
1300 500-650 800
3000 1300-1800 2500
7000 4000-4500 6000
NA >5000 >8000

Table 5: Sizes of Arterial Pump (Raceway) Tube

According Flow Rate
Patient's Flow Rate Boot (Raceway) Recommended
Tube Size Arterial Roller Head Size
(mL/min) Inch (Raceway Lengths)
Up to 500 Mini-Head ( Small Head )
500-800 Mini-Head ( Small Head )
800-1500 Standard-head ( Big Head)
1500- 4000 Standard-head ( Big Head)
Above 4000 Standard-head ( Big Head)
Roller heads maximum speed is 250 RPMs, but I chose the size of
boot (arterial pump raceway) with consideration that the maximum
heads speed that used for achievable the maximum expected flow for
patient must be not exceed 160170 RPM , because the maximum
speed are likely to involve increased hemolysis spallation and the
potential for failure.
Used the smaller raceway lengths (mini-heads) that increase the
compression rate for a given pump flow rate.

71
Table 6: Arterial and Venous Line Size as patients
weight
patients weight Arterial Line Size Line Venous Size
Inch Inch
> 3 Kg
3-6 Kg
6-9 Kg
9-20 Kg
20-35 Kg
35-50 Kg
Above 50 Kg

Each tubing size has a prime volume that can be calculated

with a known length . View Table 7 & 8 .

Table 7: Tube Priming Volume Per Meter

Tube size Tube Capacity ml/m
9 ml/m
19 ml/m
32 ml/m
72 ml/m
127 ml/m

72
Table 8: Tube Priming Volume Per Round
Head Pump Big Head Small Head
Tube Size (Diameter 15cm) (Diameter 8.5cm)
Volume Round Round Volume

Do not use with this size 1.76

7 ml/Round 3.72
12.5 ml/Round 6.24
26 ml/Round Do not use with this size
44.5 ml/Round Do not use with this size

73
Cannulas

74
 Cannulas
Selecting the appropriate cannulas to use in cardiac surgery
are important to the perfusionist. These cannula link the CBP
circuit with the patient. The cannulae of the Cardiopulmonary
bypass circuit include arterial cannula, venous cannula, antegrade
and retrograde cardioplegia cannula, left ventricular vents,
pulmonary artery vents and aortic root vents.
Features of the cannulae are discussed in this section. These
features should be considered when cannulae are chosen. Choice
of appropriate arterial and venous cannulae often create
controversy. The perfusionist wants the largest possible cannula
while the surgeon prefers the smallest possible cannula.
The perfusionist requires a certain size of cannula to achieve
the certain flows, that needed by the patient, without exceeding
pressure gradients. But in some cases, limit the size of the
cannula by the surgeon is imperative due to private surgical
considerations (according to the patients pathology).
The cannula is used to connect the CPB circuit to the patient
so take non oxygenated blood from central venous of patient, and
deliver oxygenated blood from the heart-lung machine directly
into the patients arterial system. Therefore, the required size is
determined by the patient's weight(Venous cannula) and blood
flow(Arterial cannula).
Details of the patients height and weight are necessary to
calculate the ideal flow rate by calculate the body surface area
first.
BSA can calculate by these equations:

Body surface area (BSA) in square meters (m2 ), which is

required to determine the ideal flow rate at normothermia ( Blood
Flow =BSA cardiac index) and so to select appropriately sized
Venous, arterial cannulae and oxygenator.
75
 Table 9: Blood flow rate Using the BSA
Pediatric Normal Flow Maximum Proposed
Patient Age Flow
Flow = CI X BSA Flow = CI X BSA
Newborns - 2y. 3.2 - 3 x BSA 4 x BSA
24y 2.8 x BSA 3.8 x BSA
46y 2.6 x BSA 3.6 x BSA
6 10 y 2.5 x BSA 3.4 x BSA

Adult Normal Flow Maximum Proposed

Patient Weight Flow
Flow = CI X BSA Flow = CI X BSA
> 80 Kg 2.4 x BSA 3.2 x BSA
80-100 Kg 2.4 x BSA 3.0 x BSA
<100 Kg 2.4 x BSA 2.8 x BSA

Minimum flow depends on the patient temperature, that introduce in

Pediatric chapter.

Table 10: Pump Flow Rates as Patient weight (Kg)

Patient weight (Kg) Pump flow rate (mL/Kg/min)

<3 Kg 150-200 mL/Kg/min

3-7 120-190 mL/Kg/min
7-10 Kg 100-170 mL/Kg/min
10-30 Kg 80-120 mL/Kg/min
30-50 Kg 75-100 mL/Kg/min
>50Kg 50-75 mL/Kg/min

76
 Table 11: Some commonly used cannulation sites

Venous Arterial Cardioplegia

Right atrium Proximal aorta, distal Proximal aorta, proximal to the
to the cross-clamp. cross-clamp.
Vena cava Femoral artery Coronary sinus (retrograde
delivery).
Femoral vein Axillary artery Coronary ostia
Distal aorta Bypass grafts (during CABG)

77
 The ascending aorta is the most common site of arterial
cannulation for routine cardiovascular surgery. View Figure 4:9.

71
 Dispersion Stream Arterial Cannulae
The normal single stream cannula have a high jet stream
impact flow on the wall of the aorta. Therefore arterial cannula
tip were designed to disperse the flow(Soft-flow) to decreases
velocity and jetting, and reduce the dislodge of calcified plaques
in aortic wall. View Figure 4:10 .

81
The arterial cannula size is determined by the blood flow
required.
View Table 12.

Table12: Arterial cannula size as flow required.

Flow rate(l/minute) Size Angled tip Cannula
mm French
gauge
400 2.7 8 Edwards
400-700 3.3 10 Edwards
700-1200 4 12 Edwards
1200-1600 4.7 14 Edwards
1600-2500 5.3 16 Edwards
2500-3500 6 18 Edwards
3500-4000 6.7 20 Edwards
4500-5000 7.3 22 Edwards
Above 5000 8 24 Edwards

Flow rate(l/minute) Size Straight tip Cannula

mm French
gauge
450 2 6 dlp ( Medtronic)
600-800 2.7 8 dlp( Medtronic)
800-1300 3.3 10 dlp( Medtronic)
1300-1800 4 12 dlp( Medtronic)
1700-2800 4.7 14 dlp( Medtronic)
2800-4000 5.3 16 dlp( Medtronic)
4000-4500 6 18 dlp( Medtronic)
4500-5000 6.7 20 dlp( Medtronic)
5000-5500 7.3 22 dlp( Medtronic)
The use of straight tip arterial cannula allows to employ a small
tip size without excessive in pressure , because the resistance across
the straight tip cannula is less than the resistance in angled tip
cannula .

81
Complications of aortic root cannulation
1. Inability to inserting the cannula including:
Cannula interference by adventitia .
fibrosis of aortic wall .
Too small incision.
2. Air embolism from the cannula to the circuit.
3. Injury to the back wall of the aorta
4. Persistent bleeding around Cannula or at the site after its
removal.
5. Malposition of tip to a retrograde position towards aortic
valve , or elevated position into arch vessels.
6. Dissection of aorta.
7. Abnormal cerebral perfusion, due to the direction of a jet
into an arch vessel ,that may cause irreversible cerebral
injury and reduced systemic perfusion .
8. Obstruction of the aorta in infants .
9. Occlusion the cannula by the aortic cross-clamp.
10. Inadequate size leading to high pressure and low flow
generation.
Complications of peripheral cannulation
1. Trauma to the cannulated vessel.
2. Thrombosis or embolism.
3. Hemorrhage.
4. Distal ischemia.
5. Malperfusion of cerebral and systemic circulation as a
result of cannulation of the false lumen of an aortic.
6. Dissection.
7. Infection.
Causes of aortic cannula high pressures
1- Kink in aortic cannula or line.
2- Cannula improperly positioned.
3- Cannula too small.
4- Arterial systemic pressure very high.
5- Aortic dissection.
6- Cross clamp too near of cannula.
7- Blockage in arterial filter.
82
83
 Venous cannula
Venous cannula flows drainage is usually accomplished by
gravity. However, recently there has been interest in applying
suction to the venous lines(VAVD), to improve venous return in
some cases, especially in children.
In gravity drainage, the larger venous cannula, give the lower
resistance to flow, and the better drainage. The amount of venous
drainage is determined by the central veins pressure (patient's
blood volume), the difference in level of the patient and the top
of the blood level in the venous reservoir, and the resistance in
the venous cannulas, venous line and connectors. Excessive
drainage which may be caused by an excessive negative pressure
may cause the compliant vein walls to collapse around the ends
of the venous cannulas. This may be improved by partially
occluding the clamp on the venous line, or by increasing the
systemic blood flow.
There are different types of venous cannulas available. The
most common used is the two stage cannula. It has an open tip
that is placed in the inferior vena cava (IVC), and more proximal
openings that will be located in the right atrium (partial bypass).
There are three-stage stage venous cannula that designed to
maintain excellent flow rates throughout the procedure. There are
large single stage cannula that may be placed in the right
atrium, when a two stage cannula will not go into the IVC, but it
not always drain as well as a two stage cannula.
The other method of venous cannulation is with two single
stage cannula. One is placed in the superior vena cava (SVC)
and the other in the Inferior vena cava (IVC). These are
connected to a common venous line with a Y-connector. Because
of there are some blood go around the cannula through the heart
and to the lungs ,this type of cannulation also causes the effect of
partial bypass as the two stage cannula does. When the cannula
in the SVC and IVC have umbilical tape pulled around them, all
84
blood coming to the heart is diverted to the cannulae. This is
termed total bypass. This method of venous cannulation is most
often used in congenital or valvular surgery.
In this Table(13) the suggests size of venous cannulae that
can used with certain weight categories.

Table13: Venous Cannula Size Dependent of Patient

Weight
Patient Venous cannula
Weight
Straight tip (Three Cannula) Straight tip Cannula
Cannula Angled tip Straight (Single Cannula)
(Two Cannula)
SVC IVC SVC IVC RA Single- Two- Femoral
stage stage
1-3 14 16 12 14 16 16 10
3-6 16 16 12 14 18 18 12
6-8 16 18 12 16 20 20 12
8-10 18 18 14 16 20 22 14
10-12 18 20 14 18 22 24 14
12-15 20 20 16 18 22 24 16
15-20 20 22 16 20 24 26 16
20-25 22 22 16 22 24 28 24/32 18
25-30 22 24 18 22 26 30 24/32 18
30-35 24 24 18 22 26 30 29/29 20
35-40 26 26 22 22 28 32 29/29 22
40-45 28 30 22 24 30 32 28/36 22
50-60 30 30 24 14 32 34 32/40 24
60-70 30 32 26 26 34 36 34/46 26
70-80 32 34 28 28 36 36 36/46 28
< 90 34 34 30 30 36 51 36/51 30

These sizes of venous cannula was proposed to use with open

system (depending on gravity drainage). Otherwise, when
closed system used, the vacuum assisted venous drainage
85
 applied to create a negative pressure in the venous reservoir,
that increases venous return flow with the utilization of a
reduced diameter venous cannulae ) See section Differences
Between Pediatric And Adults\ Differences in Cannulation
in Chapter 8- Page 226).
Femoral venous cannulation are rarely able to support full
flows on bypass ,it used to support circulation until cardiac
exposure is achieved and central cannulation is possible.
Superior vena cava or right atrium cannula can be added to
the femoral venous circuit to allow for full flow on bypass.

Complications of venous cannulation

1. Low cardiac output due to retraction of the heart during
IVC purse-string suture placement.
2. Air embolization especially if the atrial pressure is low .
3. Displacement the central venous catheters during Inserting
the SVC Cannula .
4. Occlude the central venous catheters during Caval tapes .
5. Atrial dysrhythmia.
6. Malpositioning of cannula tip including :
Inserting the SVC Cannula into the azygos vein.
7. Inserting the SVC Cannula into the innominate vein.
Inserting the IVC Cannula into the hepatic vein.
Inserting the RA Cannula into LA across an atrial
septal defect.
8. laceration and bleeding of the atrium from cannulation
sites.
9. laceration of the superior or inferior vena cava due to
placing the tapes around the cava during cannulation.
10. Obstructed the cava when purse-string sutures (placed in
the cava) are closed after cannula removal.

86
Causes of poor venous return during CPB
Inadequate size of cannula.
Inadequate venous pressure.
Kinks in circuit with obstruction of line.
Air lock in venous line or cannula.
Oxygenator or venous reservoir is not positioned low
enough.
Inadequate height of patient above CPB venous reservoir.
Venous cannula placed too far dawn or up, and vena cava
not draining.
Reduced venous volume related (drugs, anesthetic agents).
Non cardiac suction being used instead of pump suckers
Reduced venous volume due to bleeding .
fluid rapidly moving to interstitial area ,due to decreased
intravascular colloid osmotic pressure .
Vent or Cardioplegia line inadvertently open and draining
blood on field .

87
 Cardioplegia
Cannula
The other cannulae used during bypass are specific to certain
procedures:

1- Retrograde cardioplegia is the most common

technique of giving cardioplegia to the heart via the coronary
sinus in the reverse direction of normal blood flow (retrograde
perfusion). The cannula is placed into the coronary sinus through
the right atrium. The cannula has a balloon near its tip that when
inflated prevents the flow of the cardioplegia back into the right
atrium. . The cannulae are of two basic types: either automatic ,or
manual balloon inflation it require inflate the cuff using an
included syringe before delivering cardioplegia.

2- Antegrade cardioplegia cannulae are designed to

deliver cardioplegia solution in the aortic root or directly into
the coronary ostia in the normal direction of blood flow
(antegrade perfusion).
A. Aortic root cannula used to infuse cardioplegia directly
into the aortic root near the aortic valve. It has a short needle
tip that is placed into the aorta. The aortic valve and the aortic
cross clamp prevent flow in either direction and thus force
88
 the cardioplegia into the coronary arteries, these cannula
come in various sizes and with various lengths, with or
without a vent line to accommodate various techniques .

B. Coronary perfusion cannula is placed in the coronary

ostia, when need to give cardioplegia directly into the
coronary ostia, these cannula come in various sizes and in
different configurations. There are two common design of
coronary perfusion cannula, the small hand held cannula with
a soft tip that is placed over the coronary ostia ,and the cone
tip cannula with self-inflating balloon that insertion direct into
coronary ostia. These cannulae are used when the aortic root is
opened e.g. aortic valve replacement .

81
Antegrade Aortic Root Cannula

The antegrade cardioplegia cannulae are used to either infuse

cardioplegia solutions into the aortic root or to aspirate air from
the aorta. That have flanged collar provides a predetermined
insertion depth as well as a means of securing the cannula

Available by manufacturers:
Size of cannula: e.g. 4 Fr, 4.5Fr, 6 Fr ,7 Fr, 8 Fr, 9 Fr .
lengths of cannula: e.g. 2.5 inch ,5.5 inch , and 12.5 inch
with or without a vent line.

11
Antegrade Coronary
Perfusion Cannula

12
 Antegrade Coronary
Perfusion Cannula

Coronary Perfusion Cannulae are used for direct

cannulation to supply cardioplegic solutions to the coronary
arteries during heart operations with an external bypass. Include,
AVR, ascending aortic arch resection or other surgical
procedures where the ascending aortic arch is incised.

Available by manufacturers:
Small hand held cannula with a soft tip:
Size of cannula: e.g. 9 Fr, 10Fr , 11 Fr ,12 Fr , 14 Fr, 15 Fr .
Curve of tip: 130, 90 .
Self-inflating balloon cannula:
Size of cannula: e.g. 9 Fr , 10.5 Fr , 12 Fr,13.5 Fr , 15 Fr.
Balloons size: 4mm , 5mm , 6mm ,7mm , 8mm .
Curve of tip

13
 Cardioplegia adapters are designed to connect multiple
cardioplegia cannula and vein graft cannula to a single inlet
source, with possibility to switch between antegrade and
retrograde delivery of cardioplegia and ability to attach a vent
line to the cardioplegia cannula.

14
 Oxygenators
The oxygenator is designed to add oxygen , and remove
carbon dioxide from the venous blood .It used in two principal
modes: in cardiopulmonary bypass (CPB), and in extracorporeal
membrane oxygenation(ECMO) to oxygenate blood in longer
term life support .
The bubble oxygenator is an early implementation of the
oxygenator used for cardiopulmonary bypass in cardiac surgery.
but ,as a result of advances in material science the membrane
oxygenator has supplanted bubble oxygenator since the 1980.
Recently the heparin-coated oxygenator is gaining favor ,
because of the belief that it produce less systemic inflammation
and decrease the tendency for blood to clot in the
cardiopulmonary bypass circuit .

The Ideal oxygenator

The ideal oxygenator as one that provided:
1- Oxygenation of venous blood and carbon dioxide elimination
(Excellent gas exchange).
2- Minimum blood trauma (Soft wall ,Bio-compatibility,
Minimize Inflammatory reaction).
3- Small priming volume (Minimize hemodilution).
4- Easily assembled and safety.
5- Minimal failure incidents and easy to replace during
Cardiopulmonary bypass in the event of oxygenation
failure.

Main functions of oxygenator

1- Reservoir functions : Defoaming , filtration ,and contain
the blood.
2- Membrane (oxygenator) functions: Gas exchange, and heat
exchange.

15
 Type of oxygenators
1- Bubble Oxygenator
The typical bubble oxygenator is divided into two sections.
The first section is the mixing chamber (oxygen chamber),
where fresh gas flows into the blood through a screen, which
causes small bubbles to form. The oxygen is transferred from the
bubbles into the blood, and carbon dioxide is transferred from the
blood into the bubbles. The second section is the reservoir, where
blood is defoaming and contain in it. View Figure 4:11.

The disadvantages of bubble Oxygenator is the direct

contact between the blood and air ,that permit to formation gas
emboli . The main advantage of bubble oxygenators is the low
resistance to flow and low pressure drop across the oxygenator
compared with membrane oxygenators.

16
 2- Membrane Oxygenator
The main advantage of membrane oxygen over bubble
oxygenators is the avoid of direct contact between the blood and
air in membrane oxygen, which prevents the formation of
bubbles .Some natural or synthetic materials are permeable to
gases , this materials are used by some researchers to made gas
permeable membranes . That aimed to utilization of this material
as a gas exchange membrane to make a physical separation
between the blood and gas(O2 and CO2), this make artificial
oxygenation more similar to oxygenation in the lungs . These
material must be very thin with minimal resistance to blood , and
compatible with blood .
There are different types of materials that used in membrane
oxygenators. The most widely used of these materials is the
microporous polypropylene (hollow-fiber capillaries ).Silicone
rubber is used also in some device (True membranes). Silicone
rubber are non-porous, and gas exchange in these membranes are
depend entirely on gas diffusion through the silicone rubber.
Otherwise, the microporous polypropylene sheets or fibers have
small pores, that potentially allow physical connections between
the gas and blood.
Parts of Membrane Oxygenator:
1- Cardiotomy Reservoir.
There are two type of reservoir:
A- Flexible venous reservoirs (Soft shell reservoir).
B- Hard-shell Venous Reservoirs.
2- Membrane(oxygenator).
There are two type of membrane according to materials
that are made of:
1- Microporous Polypropylene:
(a) Hollow Fiber Structure .
(b) Flat-Sheets Membrane (Microporous Sheets).
(c) Integrated Arterial Filter With Self-Venting Technology.

2-True Membrane (Diffusion membrane).

17
 1- Cardiotomy Reservoir:
Blood reservoir is a device used in cardiopulmonary bypass
for contain the volume of blood that displacement out of the
human circulation during the operation.

Type of Cardiotomy Reservoir :

A- Soft shell reservoir:
The soft-shell reservoirs (Flexible venous reservoirs) have
the advantage of increase and reduce its size according to the
amount of blood that they contain, and they are not have
airspace, that prevent the accidental delivery of air to patient .The
venous blood enter in the reservoir through the inlet port, and
passes through micro screen and aspirate from the outlet port by
head pump to oxygenator inlet. The inlet port position is above
the outlet port which puts a larger volume above the outlet port
which promotes mixing, prevent vortex, optimize air removal,
and promotes low venous resistance. View Figure 4:12.

18
B- Hard-shell Venous Reservoirs:

Hard-shell reservoir is a hard plastic container (rigid walls)

made of polycarbonate, contains an integral filter mechanism. The
venous blood enter from the venous inlet port and passes through a
defoamer (Polyurethane foam), depth filters (Polyester, or dacron
wool), and screen filters (Polyester or polypropylene). which result
to filtration the blood from particulate materials (clots, blood cell
aggregates, fat emboli, fibrin and surgical contamination) before
leaving the venous outlet of cardiotomy. View Figure 4:13 .

The advantages of rigid reservoir: easy volume measurements

and management of venous air, larger capacity, easier to prime, and
permit suction for vacuum-assisted venous drainage. Disadvantages
include micro air bubbles due to the possibility to form the vortex,
and increased activation of blood elements.
11
 2- Membrane(oxygenator)
The membrane is consists of a plastic housing made of
polycarbonate, which contains the gas exchange membranes and
water circuit .It designed to be used to gas exchange and heat
exchange. The venous blood enter from the membrane inlet port
and leaving from the membrane outlet after provided with
oxygen and get rid of carbon dioxide. View Figure 4:14 .

The blood temperature is control through a water circulator.

The priming volume(static) of the oxygenator can be adjusted by
selecting different sizes and lengths of microporous polypropylene
(or Silicone) fibers(Low priming volume reduce hemodilution).
Microporous polypropylene fibers is highly permeate to oxygen
and most other common gases.
111
 Type of Membrane Oxygenator
1- Microporous Polypropylene:
(A) Hollow Fiber Structure:
The Microporous Polypropylene Hollow Fiber is the most
membrane oxygenators actually use. The Gas exchange in the
membrane occurs by diffusion through the membrane wall and
transit via microporous (micro channels). In previous designs the
flow of blood was through the hollow fiber and the gas
surrounded hollow fibers. But the most of the designs today rely
on the flow of gas through the hollow fibers with blood around
them, this configuration reduces blood pressure drop across the
oxygenator. View Figure 4:15.

When microporous membrane oxygenator is used, it is

extremely important that the pressure in blood side must
always exceed the pressure in the gas side (always open the gas
flow after the blood flow), to prevent the possible of entering any
gas emboli from gas side to blood side via the micro channels .
The surface tension of the blood prevents plasma water from
entering the gas side of the membrane during CPB and prevents
gas leak into the blood side.
111
 However, after several hours (about 6 hours) of use the
microporous membrane , the plasma infiltration(leaks) into the
microporous resulting to limits in gas exchange, evaporation and
condensation of serum leaking through microporous leads to
reduced oxygenation efficiency. View Figure 4:16.

Therefore, the perfusionist should be more careful when

using these types of oxygenator for more than 6 hours, after
that time the perfusionist must be increased the observation
of gas exchange, by increased blood gas samples and continuous
check to the difference of color between the arterial and venous
line, and must be ready to oxygenator replacement if need .
The membrane oxygenators have high resistance to blood
flow across membrane ,because of this the venous blood must be
aspirated from the venous reservoir and actively pumped through
the oxygenator by the roller or centrifugal pump. Excessive
pressure through the membrane can cause rupture, resulting a
blood leak or air embolism, depending on flow conditions.
112
)B) Flat-Sheets Membrane (Microporous Sheets)
"Folded-Envelope Design".
In flat sheet microporous membrane oxygenators the
membrane is a flat sheet which is folded to create plates that
separate a blood compartment from the gas compartment.
View Figure 4:16 .

The first devices of these oxygenators were introduced in

the mid-1970s.
The flat plate microporous membrane oxygenators are more
effective in trapping and expelling air bubble , that may
accidentally enter the membrane oxygenator , but they have a
larger surface area than hollow-fiber oxygenators and demand
larger priming volumes. Therefore, the folded membrane type
microporous oxygenator has been superseded by hollow fiber
oxygenators.
113
(C) Integrated Arterial Filter Oxygenator.
Integrated arterial filter oxygenator is a new generation of hollow
fiber oxygenator with integrated arterial filters, It has a screen
filter surrounds the hollow fiber layer of the oxygenator to trap
and/or remove particulate and air emboli from the blood before
return to the arterial line. The gaseous emboli that may be present
in the blood are trapped in the screen filter mesh (keep contact
with the hollow fiber) . Driven by the pressure difference (blood
side 100-300 mmHg gas side 0-15 mmHg), gaseous emboli
enter the inner lumen of the microporous hollow fiber and are
eliminated via the gas outlet . View Figure 4:17.

114
2. True Membrane (Diffusion membrane)
True membrane (Nonporous membrane) View Figure 4:17 .
oxygenators are manufactured by coiling silicone rubber sheets in
a cylindrical fashion (Silicone is a thermoset plastic; It has better
dimensional stability, heat resistance, chemical resistance).

Blood is kept on one side of the membrane and gas on the

other side . The membrane provide a complete partition between
the blood and gas so that the transfer depends totally on diffusion
of gas through the membrane material. View Figure 4:18 .

Gas transfer through the membrane is dependent on the

permeability of the membrane, the driving pressure of gas on
either side of the membrane , and the diffusion distance of the
gas in blood .

These oxygenators, have a larger surface area than hollow-

fiber oxygenators and demand larger priming volumes, and its
more expensive .

115
116
 True membrane use on in long-term support such as ECMO,
because of its ability to maintain stable gas transfer for long
periods time (days or weeks) . View Figure 4:19.

117
118
Blood Flow Path through Oxygenators
In general, the blood flow through the oxygenators are
passes in radial or axial paths .The path of blood flow is affect in
oxygenating efficiency, air emboli removal, pressure drop, and
heat exchanger performance.
The blood enters the oxygenator from blood inlet and passes
through the heat exchanger first , and then through oxygenator
bundle before exiting from blood outlet(low point in oxygenator
to prevent air emboli). View Figure 4:20 & 21 & 22 .

111
111
111
 Principles of Membrane Oxygenator
Gas transfer occurs in membrane oxygenator by diffusion .
Diffusion: is a random movement of molecules or atoms from
higher concentration area to lower concentration area.

:Diffusion of gases in membrane oxygenator depend upon

1- Partial pressure gradient of particular gas in blood and gas
phase.
2- Diffusive characteristics of a gas.
3- Concentration of particular gas.
4- Physical characteristics of membrane (surface area, flow
path, type of).

Definitions Useful in the Comparing Between Oxygenators:

Initial Priming Volume: It is a volume(ml) to fill up the

oxygenator(Membranes) , heat exchanger , and recommended
minimum venous reservoir.

Static Priming Volume: This is volume to prime oxygenator

(Membrane) without any flow.

Minimum Operating volume: Minimum volume in the

reservoir which is recommended by manufacturer to prevent
release air emboli through blood at reference maximum blood
flow.

Maximum Operating Volume (Reservoir capacity):

Maximum volume in the reservoir which is recommended by
manufacturer .

112
 Max Blood Flow: It is a flow range which is recommended
by manufacturer by considering better gas exchange, heat
exchange and pressure drop.

It is recommended to select the oxygenator based on the

maximum expected pump flows . Using an oxygenator above its
manufacturer recommended maximum flow rate may decrease
gas exchange efficiency and increase arterial line gaseous
microemboli (GME) transmission and is not recommended.

In the following tables the values that the perfusionist must

be familiar with them to be able to trade-off between the different
types of oxygenators and select the appropriate oxygenator for
his patient.

113
 Size of Oxygenators
Selected the oxygenator is based on that the maximum
expected of flows for patient must not exceed the maximum flow
of oxygenator. see table 14 ,15 ,16,&17.
Table14: Neonate Oxygenator.
(Oxygenators rated up to 1.5 LPM)
Oxygenator Max Membrane Static Minimum Initial Reservoir Heat
blood Surface priming operating Priming capacity exchanger
Flow area volume level Volume size
ml/min m mL mL mL mL m
Sorin 700 0.22 m 31 ml 10 ml 41ml 500 0.03
Dideco
KIDS D100
MAQUET 200- 0.38 m 38 ml 15 ml 53ml 800 0.07
Quadrox-i 1500
Neonatal
MAQUET 200- 0.38 m 40 ml 15 ml 55ml 800 0.07
Quadrox-i 1500
Neonatal
Terumo 100- 0.5 m 43 ml 15 ml 58ml 1000 0.035
Capiox 1500
RX5
Terumo 100- 0.5 m 43 ml 15 ml 58ml 1000 0.035
CAPIOX 1500
FX5
Sorin 800 0.34 m 60 ml 15 ml 75ml 675 0.02
Dideco
Lilliput 1
D901
MAQUET 800 0.33 m 52 ml 25 ml 77ml 400 0.05
Safe Micro
In Neonate : Total circuit priming volumes are commonly in the
range of 100-400 ml.

Oxygenator in shaded rows contain integrated arterial filter.

Initial Priming Volume (Oxygenator volume) =
Static priming volume + Minimum operating level .
Total circuit prime volume =
Oxygenator volume + circuit ( lines+ arterial filter) volume.

114
 Table15: Pediatric Oxygenator.
(Oxygenators rated up to 3.2 LPM)
Oxygenator Max Membrane Static Minimum Initial Reservoir Heat
blood Surface priming operating Priming capacity exchanger
Flow area volume level Volume size
ml/min m mL mL mL mL m
Medtronic 100- 0.67 m 48 20 ML 68ml 1200 Not
pixie 2000 ML Specified
ml/min
MAQUET 200- 0.8 m 81 30 ML 111ml 1700 0.15
Quadrox-i 2800 ML
Pediatric ml/min
Sorin 2500 0.61 m 87 30 ML 117ml 3500 0.06
Dideco ml/min ML
KIDS D101
MAQUET 200- 0.8 m 99ML 30 ML 129ml 1700 0.15
Quadrox-i 2800
Pediatric ml/min
MAQUET 300- 0.66 m 90 70 ML 160ml 2000 0.17
SAFE MINI 2300 ML
ml/min
Medtronic 500- 0.8 m 149 150 ML 299ml 2000 Not
MINIMAX 2300 ML Specified
ml/min
Sorin 2300 0.64 m 105 200 ML 305ml 3300 0.02
Dideco ml/min ML
Lilliput 2
D902
EUROSETS 500- 0.69 m 90 Not 2500 0.04
TRILLY 3200 ML Specified
EUROSETS 500- 0.84 m 130 Not 2500 0.04
TRILLY 3000 ML Specified
AF
In pediatric: Total circuit priming volumes are commonly in the
range of 200-600 ml.

Oxygenator in shaded rows contain integrated arterial filter.

Initial Priming Volume (Oxygenator volume) =
Static priming volume + Minimum operating level .
Total circuit prime volume =
Oxygenator volume + circuit ( lines+ arterial filter) volume.

115
 `Table16: Small Adult Oxygenator.
(Oxygenators rated up to 5 LPM )
Max Membrane Static Minimum Initial Reservoir Heat
blood Surface priming operatin Priming Capacity exchanger
Oxygenator Flow area volume level Volume size
ml/min m mL mL mL mL m
Terumo
CAPIOX 500-4000 1.5 m 135 mL 70 ML 205ml 3000 0.14
RX15 R30
Terumo
CAPIOX 500-4000 1 m 135 ML 70 ML 205ml 3000 0.13
SX10
Terumo
CAPIOX 500-4000 1.5 m 144 mL 70 ML 214ml 3000 0.14
FX15 R30
Sorin
Dideco D905 5000 1.1 m 160 ML 150 ML 310ml 4300
EOS
Terumo
CAPIOX 500-5000 1.5 m 135 mL 200 ML 335ml 4000 0.14
RX15 R40
Sorin 4000 1 m 140 ML 200 ML 340ml 2000 0.11
Dideco D705
Terumo
CAPIOX 500-5000 1.5 m 144 mL 200 ML 344ml 4000 0.14
FX15 R40
MAQUET
Quadrox-i 500-5000 1.3 m 175 ML 300 ML 475ml 4200 0.3
Small Adult
MAQUET
Quadrox-i 500-5000 1.3 m 295 ML 300 ML 595ml 4200 0.3
Small Adult
In small adult: Total circuit priming volumes are commonly in the
range of 700-1100 ml

Oxygenator in shaded rows contain integrated arterial filter.

Initial Priming Volume (Oxygenator volume) =
Static priming volume + Minimum operating level .
Total circuit prime volume =
Oxygenator volume + circuit ( lines+ arterial filter) volume.

116
 Cardiopulmonary Bypass Filters
There are various filters that can be used within the CPB
circuit. (see Table18) .
Table 18: Filters used within the CPB circuit and
their functio
Filter type Filter Function
Arterial line Used to remove microemboli including gas emboli,
filters fat emboli and cellular debris .
Pore size of arterial line filters generally from 20 -
40 microns.
Pre-CPB filters Used during the priming to remove particulate
contamination from circuit primer (Bacterial ,
microbial ,and endotoxin)
Pore size 0.2 m.
(m = micrometer = 1 (1/1000 millimeter)
Gas line filters Used to remove particulate and microbial
contamination from gas lines.
Pore size 0.02 m .
Cardioplegia Removes particulate debris and microbial
filters contaminants and endotoxins.
Pore size : Blood cardioplegia: 20- 40 m.
Crystalloid cardioplegia: 0.2 m.
Leukocyte Reduces the levels of leukocytes from the arterial
depletion filters line or cardioplegia system .
Pore size >40m.
Blood Screen-type filter designed to reduce micro-
Transfusion aggregates and debris (These range in size from
filters 170260 m) from stored or salvaged blood.
(Microaggregate Largest pore size(200 m) can be used for rapid
blood filters transfusion to treat profuse hemorrhage . Micro
"MBFs" ) filters with a pore size of 10-40 m may be used for
more effective elimination of harmful blood
components, micro-aggregates, and non-blood
component particulate matter .
Cell sever Used to remove debris such as foreign matter, fibrin,
(Cell salvage) and cell clumps from salvaged blood .
Pore size 20- 40m.

118
 Blood Filters
Filter Types
There are two primary types of filters used for blood
filtration during CPB: depth filters and screen filters.

1- Depth filters: Consist of packed fibers of dacron wool or

polyurethane foam . These filters have large wetted surface
areas to filter the blood by absorption , they are effective in
trapping gross bubbles.

In depth filters, the particulate removal depends on:

A- The amount of wetted surface area .
B- The filter thickness, tightness ,tortuosity, and material .
C- The chemical structure of the particles .
D- The diameter of blood flow pathways .

2- Screen filters: Screen filters are composed of a woven

mesh of polyester fibers ,with defined pore sizes in the
mesh (from 20 -40 m) to determine its filtration ability .

Virtually all of the arterial line filters used are the screen
type. Most arterial line screen filters have pleats to increase the
surface area and permit acceptable blood pressure drop at clinical
flow rates. Particulate material is trapped in these filters because
the particles are larger than the pores, gaseous microemboli are
also trapped due to surface tension effects from the wetted pores.
The cardiotomy reservoir receives the venous blood which
contains a large amount of debris along with room air, therefore
it contains an integral filter mechanism that relies on a
combination of both depth and screen filters.

111
 Arterial Line Filters
Arterial line filters are the most important component of the
cardiopulmonary bypass circuit to limit sources of embolic load
to the patient through the perfusion circuit. Arterial line filters are
a screen type composed of a woven mesh with a pore size larger
than 20 m to permit adequate blood flow without excessive
blood pressure drop.
Arterial line filters remove the gaseous microemboli by
surface-active forces on the wetted pores ,a sudden decrease in
flow velocity when the blood contacts the wetted mesh after
entering the filter causes the air bubbles to rise to the top of the
filter where they can be purged from the system. The new
generation of filters allows the blood to enter the filter in a
tangential pattern ,that increases the probability of air to rise to
the top of the filter. There are some filters (Auto-vent filters)
which have a microporous hydrophobic membrane integrated
into the top of the filter, this allows automatic purging of
entrapped air to the atmosphere. View Figure 4: 23 .

Most arterial line filters are prepared with pleats and folds to
increase the available filtration surface area and efficiency . But ,
if filtration is required for a long period the efficiency may be
reduced due to blockage of available pores.
121
 The following table is commonly available types of arterial
line filters
Table 19: Most Common Types of Arterial line Filters
Prime Maximum Surface Pressure Pore
Type ml
Flow
ml/min
Area
cm
drop
mmHg
Diameter
m
Not
Dideco KIDS D130 16 700 11 40
Specified
Not
Dideco KIDS D131 28 2500 40
Specified
Terumo Pall AL3 28 3000 175 30 40
EUROSETS BABY Not
35 3200 24 40
SHERLOCK Specified
Not
Medtronic Affinity Pixie 39 3200 30
Specified
Dideco D735 40 2500 140 68 27
Dideco D736 40 2500 140 70 40
Terumo CAPIOX AF02 40 2500 16 25 32
EUROSETS MINI Not
90 5000 40
SHERLOCK (A.F.) Specified
Dideco D731 100 5000 300 45 27
Dideco D733 100 5000 300 40 40
Terumo Pall AL6X 100 8000 550 15 32
Terumo Pall AL6 100 8000 550 15 40
Terumo CAPIOX AF125 125 7000 637 36 37
Terumo Pall AL8 170 8000 630 42 40
EUROSETS SHERLOCK Not
179 8000 600 40
(A.F.) Specified
Not
Maquet QUART 180 7000 40
Specified
EUROSETS SHERLOCK Not
185 7000 105
(B.T.) Specified
Dideco D 732 195 7000 655 60 27
Dideco D734 195 7000 655 45 40
Terumo CAPIOX AF200x 200 7000 34 37
Not
Medtronic Affinity 212 7000 20
Specified
Not
Medtronic Affinity 212 7000 38
Specified
Terumo Pall AutoVent 220 6000 645 50 40

Pressure drop (blood flow) for filters are measured at maximum

flow .
Terumo: The x appearing after model number means: with
Xcoating (surface coating) .

121
 White Cell Filters (leukocyte-depleting)
In recent years there has been increasing recognition of
adverse effects of activated white cells during blood transfusion
to the CPB circuit ,it may lead to an inflammatory response to
CPB . Many cardiac centers now choose to use white cell free
homologous blood ( the majority of white cells have been
removed prior to addition to the bypass circuit).
Leukocyte-depleting techniques may be included in the
bypass setup by using arterial line leukocyte reduction filters to
continuously filter white cells throughout the cardiopulmonary
bypass period , this technique has demonstrated some clinical
benefits.
The new generation of leukocyte-depleting filters are composed
of synthetic microfiber materials prepared as a non-woven mesh.
These filters remove 99.9% of the leukocytes from the blood.
These filters are composed of depth or screen filter types. View
Figure 4: 24 .

122
 Hemoconcentrators Hemofilter
Hemoconcentrators (ultrafilters) blood filter are devices mainly
consisting of a hollow fiber semipermeable membrane to allow
the passage of water and electrolytes from the blood to a filtrate
chamber and waste bag. View Figure 4: 25 .

Hemoconcentrators are used during extracorporeal

circulation to remove excess fluid and electrolytes (e.g. excess
potassium levels), remove inflammatory mediators generated and
raise hematocrit.
123
 The size of the molecules which are removed by the
Hemoconcentrators blood filter are dependent on the pore size of
the hemoconcentrators membrane, usually molecules up to
20000 Daltons are removed (e.g. water, electrolytes, heparin
and various inflammatory mediators).

However, hemoconcentrators filter cannot remove plasma

proteins and blood coagulation factors (albumin, AT III,
immunoglobulins, ..) because the plasma protein molecules
mass are above 65 000 Daltons, this maintains the plasma
colloid oncotic pressure. The hemoconcentrator is normally
connected to the CPB circuit at the systemic flow line or port, to
provide a driving force(high pressure) to pump blood through the
device, where blood is filtered before being returned to the
patient. The speed of fluid removal is usually 30 to 50 ml/minute,
and depends on the hematocrit level, the membrane pore size and
the pressure in the hemoconcentrator membrane.
Hemofiltration may be used during or after cardiopulmonary
bypass (MUF), to manage hyperkalemia, or for hemoconcentration
if the hematocrit is low and circulating volume is adequate.. A
small priming volume hemoconcentrators (e.g. 8 cc) are used
during neonatal heart surgery to avoid excess circuit volume.
Using hemoconcentrator for the cases with long bypass times
exceeding 1.5 h is a benefit to get rid of inflammatory mediators
(associated with long pump times), even in the absence of extra
circuit volume, by adding a balanced electrolyte solution to the
circulating volume and then removing that same amount of volume
with the hemoconcentrator. Also, high potassium levels with the
absence of extra circuit volume can be managed with aggressive
ultrafiltration by using normal saline to wash out the excess
potassium. Normal saline and electrolyte solution is relatively
acidotic, so NaHco3 must be added to buffer the acidity when
using this technique.
124
 Advantage of Hemoconcentration
1- Reduction of homologous blood and blood products
needed.
2- Increasing hematocrit level, that improves arterial oxygen
content and maintains an adequate oxygen delivery to
body.
3- Decreases post-operative bleeding as platelets and clotting
factors are kept.
4- Controls the intracellular water level by retaining plasma
proteins, and decreases tissue edema and organ dysfunction.
Table 20: Most Commonly Available Types of
Hemoconcentrators Filters
Filter Fibers material Surface Pressure Fiber
Type Priming Area drop Diameter
ml m2 mmHg m
Hemocor HPH Junior 8 Polysulfone 0.09 55 200 m
14
Hemocor HPH Mini Polysulfone 0.07 30 620 m
Hemocor HPH 400 27 Polysulfone 0.3 61 200 m
Hemocor HPH 700 56 Polysulfone 0.71 142 200 m
Hemocor HPH 1000 84 Polysulfone 1.1 85 200 m
Hemocor HPH 1400 100 Polysulfone 1.3 78 200 m
Medos pro 20 17 Polyurethane 0. 2 53 215 m
Medos pro 60 52 Polyurethane 0. 2 40 215 m
Medos pro 140 102 Polyurethane 1.4 44 215 m
Dideco DHF02 30 Polyethersulfone 0.25 200 m
Dideco DHF06 60 Polyethersulfone 0,68
Dideco SH14 80 Polyethersulfone 1,35
Terumo CAPIOX
34 Polysulfone 0. 5
HC05
Terumo CAPIOX
67 Polysulfone 1.1
HC11
MAQUET BC 20 plus 17 Polysulfone 0. 22 215 m
MAQUET BC 60 plus 51 Polysulfone 0. 65 215 m
MAQUET BC 140 plus 102 Polysulfone 1. 35 215 m

125
 Modified Ultrafiltration

Modified ultrafiltration(MUF) is a technique used to

concentrate the patients circulating blood volume and the
residual volume in the extracorporeal circuit at the end of
cardiopulmonary bypass.

The extracorporeal circuit contains a significant amount of

diluted residual autologous whole blood, which is present at the
end of cardiopulmonary bypass. Usually, this residual blood is
discarded, due to it excess diluted blood, and it contains a
significant amount of activated mediators. The technique of
modified ultrafiltration was introduced in the early 1990s, to
concentrate and reinfuse the residual blood from the
extracorporeal circuit.This blood conservation technique allows
hemoconcentration of the patients circulating blood volume
along with the residual whole blood in the extracorporeal circuit
including the venous reservoir after bypass has been terminated.

The hemoconcentrator inlet is connected to the arterial line

and the outlet to the right atrium. Blood is drawn retrograde from
the arterial cannula along from the venous reservoir (through the
membranes) by a roller pump which is connected to the ultrafilter
to allow the precise control of the blood flow through the
hemoconcentrator. A negative pressure can be applied to the
ultrafilter to increase the rate of filtration. The filtered blood is
returned to the patient through the right atrium. The use of
modified ultrafiltration for 1020 minutes after bypass can allow
to increase the patients hematocrit levels from 25% during CPB
to 35% .

126
 Many cardiac centers have reported beneficial effects with
modified ultrafiltration and it is now applied as a means of
volume control and blood preservation. An improvement in
hematocrit level, blood pressure, cardiac output, arterial oxygen
content, and clinical outcome has been documented. MUF has
been shown to improve myocardial contractility, decrease
myocardial oedema, reduce blood loss and transfusion
requirements, improvements in postoperative morbidity are due
to the removal of plasma inflammatory mediators.
For more explanation see page 271 in pediatric chapter.

127
 Intraoperative Cell Saver
nnnnThe cell saver (Autotransfusion) is a machine used to
collect lost blood from the operative field and separate RBCs
from whole blood, then washes them reinfuse them back to the
patient as a red blood cells.m

Indications For Use:

Patient has a rare blood groups or multiple antibodies.

The anticipated blood loss during surgical procedure is
large.
Patient has risk factors for bleeding.
low preoperative hemoglobin .
Patients are unwilling to receive donor blood, for moral,
religious or other reasons.

Contraindications For Use:

Blood contaminated with bacterial infections .
Patient has sickle cell disease, or abnormal red cell
disorders.
Patient has malignant cells.
Blood contaminated with gastrointestinal contents in the
surgical field (aspirated gastrointestinal contents into the
system may cause enzymatic hemolysis).

Disposable Equipment:
Cell Saver disposable set.
1000 cc bag NaCl 0.9%(3 5 units).
Transfer pack.
30,000 units of heparin .
128
 Processing Stages
There are four main processing stages of the intraoperative
cell sever (ICS):

1- Collection. 2- Separation.

3- Washing. 4- Reinfusion.

1-Collection :The blood is collected from the operative field

using a double-lumen suction tubing. It consists of two part, larger
lumen connects with the reservoir to provide the suction of blood ,
and the smaller lumen connects with heparinized normal saline
(0.9% NaCl) bag to carry heparinized saline (30,000 IU\ L) to
the suction catheter tip and drip into a mixing chamber to prevent
blood from clotting. The anticoagulated blood is aspirated by low
suction into a collection reservoir. In the reservoir the blood
passes through defomer, and filter that removes clots, body
tissues, damaged platelets, and other cellular debris. The
anticoagulated blood is stored until centrifusion is desired.

2-Separation (separates the RBC from the whole blood):

The filtered anticoagulated blood is pumped into the spinning
bowl (centrifuge bowl). In the centrifuge bowl blood is
separated into its constituent components, based on the
differential densities of the components. The most dense
component of blood are red blood cells, therefore will settle at
the bottom and the perimeter of the bowl .The lower density
components (plasma, remaining components and anticoagulant)
float inward toward the bowl center. While the bowl is filling, the
RBC component is retained within the bowl while the lighter
121
components are displaced from the bowl through the outlet line
to the waste bag. View Figure 4:26.

3-Washing: After the bowl is filled with red blood cells, the
red blood cells are washed by infusing a normal saline
solution(0.9% NaCl) into the centrifuge bowl and circulated
through the red cell layer, to displace the remainder of
contaminants (debris, plasma ,and anticoagulants) that werent
removed during the separation phase. The remaining components
and excess normal saline (0.9% NaCl) overflows through the
outlet port and into the waste bag. After the wash cycle finishes,
the centrifuge is stopped. The washed red blood cells are
aspirated from the inlet port and pumped into a collection bag,
this blood can have hematocrit as high as 60% .

4-Reinfusion: The washed Red Blood Cells contain only the

RBCs with trace amounts of WBCs and platelets but
Unfortunately, is devoid of all clotting factors . Washed red blood
cells usually reinfused immediately after collection and cannot be
stored for more than 4 hours at room temperature ,and within
24 hours when stored at 6 C. The blood can be returned to the
131
patient in a transfer bag with note (Red Blood Cells), date and
time. the washed blood will be reinfused directly into the patient
but if the patient has bleeding or low volume, you can use the
pump to transfuse it back to the patient. View Figure 4:27.

131
 Surface coatings
Extracorporeal circulation procedures have been shown to
induce complement and leukocyte activation, release of
endotoxin and inflammatory mediators, and platelet activating
factors.
The use of biocompatible coatings has been demonstrated to
reduce these unwanted effects of bypass, thereby reducing
platelet activation and ameliorating postoperative bleeding.
The aim of surface coatings is to enhance the
biocompatibility between the blood and the various artificial
surfaces of the extracorporeal circuit to reduce the risk of
thrombosis.
The small babies are much more susceptible to inflammatory
response due to the larger volume and foreign surface area of the
extracorporeal circuit. For that reason, types of coating have been
developed to create a more biocompatible CPB circuit. A further
improvement in surface characteristics of the CPB circuit to
improve the compatibility of these surface with the blood, by
modified its through treatment its via polymer materials(coating-
techniques), may be effective to reduce thrombogenic or
inflammatory reactions.
Heparin, phosphorylcholine (antithrombogenic), synthetic
polymer, and titanium nitride coating recently introduced to
reduce the inflammatory reactions on cardiopulmonary bypass.
1- Heparin Coating of the CPB circuit reduces the
inflammatory response, complement activation, and platelet
activation. The major advantage of heparin coating is the
enhanced thrombo-resistance that allows a lower level of
systemic anticoagulation to be used (by reducing the total dose of
heparin required). This may lead to reduced postoperative
bleeding.

132
 2-Phosphorylcholine Coating of the CPB circuit aims to
mimic the natural outer cell membrane, reducing the interaction
between plasma proteins and the inner surface. Thus reduce
platelet activation and postoperative blood loss.
3-Synthetic Polymer(Synthetic polypeptide) Coating
(Diamond-like Carbon) is a layer binds to the foreign surface of
circuit, that makes these surfaces hydrophilic ( having a tendency
to absorbs water). This leads to accelerated wetting of these
surfaces, the hydrophilic side forms a smoothness interface on
which the blood proteins can flows without adhering or
denaturing. These coatings minimize platelet adhesions and
activation, and improve performance .
4-Titanium nitride (TiN) coating is wear resistant, widely
used in ventricular assist device (VAD) as hard tissue
replacements to reduces friction, and improve biocompatibility.
In the flowing table some types of surface coting .

Table 21 : Most Common Types of Surface Coting

Coating Coating type
Name Manufacture
Carmeda Medtronic Covalent heparin bonding

Trillium Medtronic Covalent heparin bonding

Duraflo II Edwards Covalent heparin bonding

Phisio Sorin Group Synthetic Phosphorylcholine coating(heparin-

free)

Bioline MAQUET Covalent heparin bonding

Softline MAQUET Synthetic polymer coating(heparin-free )

X coting Terumo Synthetic polymer coating(heparin-free )

133
134
135
 Safety Checks and Setup
of the Circuit
Patient safety is the first concern for perfusionists in order to
gain best results and outcome for patients, to achieve this safety
certain protocols are a must and need to be followed and applied
by perfusionists, these protocols starts before assembling circuits
on machines, and followed by other safety procedures like
bubble traps, air bubble detectors, and level sensors, many
institutes and hospitals has their own check lists, in this part we
will gather safety checks.
Checking the heartlung machine and accessories
1: Connection checks:
Checking the cables ,plugs ,and sockets .
All cables should be placed away from movement to avoid
any accidents , or cable damage.
Checking the power supply for the heater-cooler and pump
light.
Connect the gas hoses to the gas source, and Checking the
gas supplies of air and oxygen
Checking the mixers flow meters for leaks.

2: Pump head checks:

power on.
The pump heads are free from foreign bodies.
The Rollers and guides move smoothly.
The pump heads rotate in the correct direction.
Calibrate flow scale rpm to lpm on control panels for roller
pumps.
Availability of winding handles in case of power failure is a
must.
The size of tubing inserts are correct for the tubes size used.

136
 The tubing should be aligned (not ride up or down) within
the pump housing.
Properly assembled roller pump tubing must resembles a
"U" shape (The tube is adjacent to the head wall),
advantages of that are: avoiding more tight non needed
occlusion, lowering the load on head pump, decreasing
spallation and hemolysis.

3: Electrical safety device checks:

5. Battery backup (UPS) is charged.
6. Turn on the pump heads, and unplug the power cable of
the CPB machine to ascertain that the power failure alarm ,
and backup battery are working properly.
7. Pressure transducers are calibrated.
8. Level detectors are working properly .
9. Bubble detectors are working properly.

Setup of disposable heart lung equipment

Set up time
The responsible Perfusionist takes 10-15 minutes to set up a
CPB circuit.
Set up shelf life
The set up can be kept on standby for up to 3 weeks
without priming (Dry).
but if the set-up is with prime it depends of the type of prime
fluid:
If the prime is just electrolyte crystalloid fluids such as
Ringers solution you can be kept on standby for 1 week.
But if you use a mixed fluid such as Ringers solution ,
Mannitol and Albumin or HAES, it must be used within
8 hours, or flush your circuit with a good amount of
normal saline depending on the oxygenator and tube
circuit size , then it can be kept on standby for 1 week.

137
 That is particularly true when assembling CPB circuits using
a sterile technique ,all ports should be sealed (closed) tightly
with provided caps , and water lines are not connected with
the oxygenator.

Note : In case of coating circuits and oxygenators, manufacture

guide lines and instructions must be considered.

1. The Hard shell Venous Reservoir setup:

A- It should be check expire dates.
B- It should be check sterility for pack (if the pack opened or
damaged dont use the materials inside),then removed it from
the package and examined for any defects.
C- Place the venous reservoir(or integrated reservoir-membrane)
on its holder and orient it to allow full view of the reservoir
D- Remove the yellow gas vent port cap located on the top of the
reservoir.
E- Connect the pump header line to the venous reservoir outlet
and oxygenator (membrane) inlet.
F- Connect the venous line to the venous inlet port.
G- Connect any suction port required.
Warning: Unused ports should be sealed (closed) tightly with provided caps.
H- Connect the recirculation line to the recirculation port on the
venous inlet.

138
2: The oxygenator (membranes) setup:
A- It should be check expire dates.
B- It should be check sterility for pack (if the pack opened or
damaged dont use the materials inside),then removed it
from the package and examined for any defects.
A- Place the membrane carefully on its holder. Be sure that
the venous reservoir is higher than the membrane.
B- Connect the water inlet and outlet lines to the heat
exchanger water ports. Start water flow and check for leaks
from the water compartment.
Caution: If leaks are observed, do not use. Set up the standby oxygenator.
Caution: Heat exchanger water temperature should not exceed 42C. High
temperature may result in blood damage.
Caution: The temperature gradient between blood and heat exchange water
should not exceed 8C for Pediatric and 12C in Adult.
Caution: Use the inlet port for water supply and the outlet port for water
drainage. Otherwise the heat exchange will not be performed
efficiently.
Caution: If you set up the oxygenator for standby only do not use water to check
for membrane leaks, use air pressure(300mmHg) to keep it sterile and
keep water lines without being connected to the oxygenator .
C- Connect the gas line to the gas inlet port.
Warning: always open the gas flow after the blood flow , or after aortic
cannulation(Arterial line Open).The pressure in blood side must
always exceed the pressure in the gas side (0-15 mmHg) to prevent
gas emboli in blood side.
D- Remove the cap from the gas outlet port.
Warning: do not obstruct the gas outlet port to avoid excess pressure in gas
side to prevent gas emboli in blood side.

E- In integrated arterial filters without self-venting the pre-

membrane air purge line must remain open to ensure
proper air removal.
Warning: During recirculation ,do not use pulsatile flow or stop blood pump
suddenly. Otherwise gaseous emboli may enter the blood phase from
gas phase due to inertia force.
Warning: During use of pulsatile flow, arterial filter(screen filter) must be used
to prevent inter air embolism from entering in the arterial line .
Warning: During use of VAVD techniques, arterial filter should be used.

131
3: Arterial line filters setup if demanded:
A. It should be check expire dates.
B. It should be check sterility for pack (if the pack opened or
damaged dont use the materials inside),then removed it
from the package and examined for any defects.
C. Place the arterial filter carefully on its holder avoiding any
kinking of lines.
D. Connect the pressure line to the vent port of the arterial filter
(on 3-ways stopcock ) and connect the end of the pressure
line to the pressure transducer inlet.
E. Enter the pressure setting(warning and limit) in the control
monitor .
If the pressure exceeds a set warning(usually 300 mmHg)
the pump will alarming.
If the line pressure exceeds a set limit (usually350 mmHg),
the pump will stop.
If a self-venting arterial filter was used, the pressure line can
connected to any vent port after the outlet port of the arterial
pump, with the consideration of the difference in pressure
between each point on the arterial line. Adjusting the pressure
settings (warning and limit rate) depends on the site of port
(before the membrane is the highest pressure point 300-460
mmHg; after the membrane is less than that 200 -350 mmHg
,these pressure drops result from the resistance that originates
from encounters of blood with membrane fibers; after the arterial
filter is the lowest pressure point 100 200 mmHg, the pressure
drop here results from encounters of blood with a mesh of
arterial filters).
* after priming a test for pressure must be done by closing all
recirculation lines and clamp the arterial line after the
pressure line to assure that the alarm limit is working and
machine is responding to that alarm, for this test the CPB
machine shall stop directly otherwise a defect in the machine
is occurred and must be checked .
141
4: The cardioplegia system setup if demanded:
A- It should be check expire dates.
B- It should be check sterility for pack (if the pack opened or
damaged dont use the materials inside),then removed it
from the package and examined for any defects.
C- Place the cardioplegia carefully on its holder.
D- Connect the water lines to the cardioplegia administration
set ,and start water flow to ensure that it is free from leaks.
E- Assemble circuit according to the instructions from the
manufacturers manual.
F- The cardioplegia pressure transducer and purge lines are
connected to the cardioplegia delivery device.

5: The centrifugal pump setup if demanded:

A- It should be check expire dates.
B- It should be check sterility for pack (if the pack opened or
damaged dont use the materials inside),then removed it
from the package and examined for any defects.
C- Checked the head motor is free from dirt or foreign bodies
to maintain the function of the device.
D- Place the centrifugal cones carefully on the centrifugal
head motor.
E- Connect the PVC tube to the outlet of the venous reservoir
and connect the other end of the tube to the inlet port of the
centrifugal cones.
F- Connect another tube to the outlet port of the centrifugal
cones and connect the other end of the tube to the
oxygenator inlet port.
G- Ensure that the relevant handles-crank is available in case
of power failure.

141
 Administration of Priming Fluids

The first trials of CPB usage in practice suggested to use

fresh blood to fill the CPB circuit. However this caused an
overload in blood banks and limited the ability to execute the
number of procedures planned.

Then ,as an alternative for using fresh blood, stored blood

which was preserved in a citrate solution was used. However, the
use of fresh or citrated homologous blood to fill CPB circuits was
associated with a complex conditions at the start of the perfusion
including arterial hypertension and a drop in the venous return.
Other complications included excessive hemolysis, denaturation
of proteins ,transfusion reactions, viral particle transmission, and
increased postoperative morbidity.

After that, a reduction of blood usage was sought and the

priming solution was used only to fill the cardiopulmonary
bypass circuit. This system introduced hemodilution using saline
solution in the oxygenator to replace the blood, with maintenance
of the oxygenation during perfusion. Otherwise, if the
hemodilution is not carefully performed, hemoglobin levels may
be decreased, resulting in a reduction in oxygen content and
transportation of oxygen to the tissues and hypoxia may occur
despite of high pO2 levels in the arterial blood. Other
complications can result due to an increase in hydration, these
lead to the necessity of hemofiltration techniques.

142
 The issue of selecting the right priming solution for
cardiopulmonary bypass circuit is imperative. Basically, priming
solutions can be classified into two categories, crystalloids and
colloids. The crystalloids include dextrose, balanced crystalloid
fluids (e.g. Plasma-Lyte, Ringer's) , and mannitol, and the
colloids include albumin, dextran's, gelatins, and hydroxyethyl
starch (Haes-Steril).

The crystalloids are a volume expanding solutions that

mimic the normal plasma electrolyte concentrations, can be used
with effective hemodilution but they lack oncotic activity.
Otherwise, colloids have ability to maintain the oncotic pressure
and reducing tissue oedema, but their use may be associated
with increased incidence of anaphylactoid reactions and clinical
coagulopathy.

143
 Crystalloids as priming solution
Crystalloids have minor components that are easily mixed
and dissolve in a solution. The components (solutes) may be
electrolytes(e.g. Normal saline, Ringer's Lactate or Solution) or
nonelectrolytes (e.g. Dextrose) which are composed of small
molecules that have ability to transit across the semipermeable
membrane and mobility from bloodstream into cells and body
tissues. This ability may increase the fluid volume in both
interstitial and intravascular spaces, but the general effect of the
crystalloid fluids is to expand the interstitial volume rather than
the plasma volume.

There are three types of crystalloids:

Hypertonic crystalloid: Crystalloid solution that has a higher
concentration of electrolytes than the body plasma(Causes water
to shift from the extravascular spaces to the intravascular space).
Hypotonic crystalloid: Crystalloid solution that has a lower
concentration of electrolytes than the body plasma(Causes water
to shift from the intravascular space to the extravascular space).
Isotonic crystalloid: crystalloid solution that has the same
concentration of electrolytes as the body plasma [not causing a
significant shift of water between the body compartments (ECF:
Extracellular fluid, ICF: Intracellular fluid ,ISF: Interstitial
fluid)].

In the following commonly used priming crystalloid

fluids and their characteristics:
1-Dextrose: Dextrose was one of the first crystalloids that
was used as priming solution for filling cardiopulmonary bypass
circuits following the abandonment of blood priming. Dextrose
5% in Water is isotonic and acidotic(pH 5.0) .

144
 When comparing the use of crystalloid fluids with the
banked blood use as priming solution for cardiopulmonary
bypass circuits, the crystalloids have a beneficial effects on
reducing the mechanical damage to erythrocytes and on
improving intraoperative and postoperative diuresis. Furthermore
,crystalloid prime containing dextrose has also led to decreased
peri-operative fluid requirement and reduced postoperative fluid
retention .
Disadvantages of using dextrose as a priming solution:
1- may cause systemic metabolic acidosis.
2- may increase the level of blood glucose, especially in
diabetic patients.
3- Possibility of increase the risk of neurological complications
of cardiopulmonary bypass.
2-Balanced crystalloid fluids:
Balanced crystalloids are fluids that have a neutral pH as
Plasma-Lyte solution (pH 7.4), or slightly low pH (slightly
acidotic) as Ringer's (pH 6.6), which are isotonic and consist of
electrolyte ions approximately similar to that of human plasma.
Ringer's lactate, or Hartmann's (Ringer's solution), is a
typical example of a balanced crystalloid. Ringer's lactate
contains lactate as a source of bicarbonate. But, as lactate may
be converted into glucose in vivo through the gluconeogenic
pathway, as result of that we must be careful when using a large
volume of fluid containing lactate in diabetic patients.
Another example of a balanced crystalloid is Plasma-Lyte
solution, which contains acetate and gluconate for bicarbonate
production, and magnesium (intracellular cation) which is
important in cellular process of energy transfer and in myocardial
ATP metabolism..
The balance in Ringer's lactate or Plasma-Lyte is resulting
from metabolizing of lactate (In Ringer's lactate) and acetate(In
145
Plasma-Lyte). Both lactate and acetate are ultimately metabolized
to bicarbonate in the liver.

3-Mannitol:
Mannitol is a hypertonic, acidotic (pH 4.5 7.0), and low
molecular weight (182 Da) crystalloid. It widely used in
clinical practice to stimulate diuresis.
Mannitol is used also as a volume expander, initially it draws
the fluid across the capillary to the plasma. Then the mannitol
diffuses rapidly into the interstitial fluid and draws water from the
body cells to extracellular phase, resulting increase in the volume
of the extracellular phase or compartment. Mannitol have a
protective effect on renal function, and have a beneficial effects on
all organs, including the brain and heart. Mannitol is commonly
used with circuit prime of cardiopulmonary bypass. The amount
usually administered is 0.5-1 g/kg . The diuretic effect of mannitol
continue for up to 12 h. It is classified as an osmatic diuretic.

146
 Colloids as priming solution
Colloid solutions are a fluids containing large proteins or
high molecular weight substance (generally MW > 30,000 Da)
substance, that tend to stay within the vascular space (blood
vessels) greater than crystalloids (do not pass across capillary
walls as easily as crystalloids).
Definitions Useful in Discussion the Colloids Solutions:
Colloid osmotic pressure (Oncotic pressure) is a form of
osmotic pressure exerted by proteins or other high
molecular weight substance in a blood vessel's , that
usually tends to pull water from extravascular spaces to the
Intravascular spaces . It is the opposing force to capillary
filtration pressure and interstitial colloidal osmotic
pressure .
Extravascular spaces is the space outside the vessels
consisting of the intracellular and interstitial space.
Intracellular space is the space within the cells.
Interstitial space is the space located between cells.
Intravascular space is the space within the blood vessels.
The usage of colloid fluids in priming solution for
cardiopulmonary bypass is beneficial in maintaining of plasma
volume during the entire period of operation. Colloid fluids have
a greater tendency to stay in the intravascular space and enhance
the plasma volume, so infusion of colloid fluids into the vascular
space leads to a longer lasting expansion in plasma volume as
compared to crystalloid fluids. Most of this potency is related to
the colloid osmotic pressure exerted by each fluid.
Colloids solutions are effective in maintaining colloid osmotic
(oncotic) pressure across the wall of the capillaries. Albumin
solutions and various other colloids solutions containing artificial
colloids are available. selection of colloids has commonly been
based on cost, and appropriateness to patient condition.

147
Colloids are divided for two types:
1- Natural( human albumin).
2- Artificial(dextran solutions, gelatin, and HES).
The following are commonly available colloid fluids and their
characteristics:
1-Albumin: Albumin is the most common natural colloid,
it constitutes 50 - 60% of all plasma proteins ,it is acidotic (pH
6.9). Albumin performs multiple functions, including transport
of many small molecules in the blood ( bilirubin, calcium, and
magnesium),contributes for 75% to 80% of the normal
osmotic pressure, and responsible for the maintenance of body
plasma volume. Albumin is produced only by the liver, and has
a half-life 15-20 days in the body and 2 days in plasma.
Albumin consists of a single polypeptide chain of 585 amino
acids ,with has a molecular weight of about 69,000 daltons.
In case of using albumin in priming fluid for cardiopulmonary
bypass circuit, albumin is usually used in combination with
crystalloid fluids. The amount of albumin used in circuit prime is
between 2.5 - 5 gm per 100ml of priming solution, to avoid
decreasing intravascular colloid osmotic pressure that could be
caused by the infusion of crystalloid fluid.
The usage of albumin in priming solution for cardiopulmonary
bypass showed favourable results for maintaining colloid osmotic
pressure comparing with the use of crystalloid priming without
albumin.
5% albumin solutions (50 g/L or 5 g/dL) have a colloid
osmotic pressure of 20-29 mmHg and thus is similar in oncotic
activity to plasma.25% albumin solutions (250g/L or 25 g/dL)
have a colloid osmotic pressure of 70-120 mm Hg . Degree of
volume expansion of 25%Albumin has a greater degree of
volume expansion as compared to other colloids. 5% albumin
solution has a similar degree of volume expansion as compared

148
to Hydroxyethyl starch (HAES) ,and smaller than gelatins and
dextrans. The oncotic effects of albumin last 12 to 18 hours.
Because albumin preparations are heat-treated(Albumin
heated to 60C for 10 h and then sterilized by ultrafiltration),
there is no risk of viral transmission. Furthermore, albumin prime
is associated with minimum side effects like allergic reactions,
anaphylactoid reactions and coagulation abnormalities compared
to synthetic colloids.
The disadvantages: Albumin is expensive as compared with
other colloids.
2-Dextrans:
Dextrans are complex branched polysaccharide molecules
made of many glucose molecules, it is acidotic (pH 4.5), they
are available for use as an artificial colloids in two formulations,
Dextran 40 with an average molecular weight of 40,000 daltons,
and Dextran 70 with an average molecular weight of solution
70,000 daltons. They are produced from sucrose by synthesis
using the bacterial enzyme dextran (certain lactic acid bacteria).
Dextran 40 has a colloid osmotic pressure twice as much as
that of plasma, so it is strong volume expander, has a strong
effect in drawing water from the extravascular into the
intravascular space.
Dextran 40 prepared in 10% solution is a more effective
volume expander than dextran 70, because it contains almost
twice as much colloid per liter (Dextran 40 10% COP= 160
mmHg, Dextran70 6% COP= 78 mmHg).However, the duration
action of the dextran 40 is much less than dextran 70, because
dextran 40 has small molecules that allows it to be rapidly
eliminated by the kidneys. Both dextran-40 and dextran-70 lead
to a higher volume expansion as compared to HES and 5%
albumin. The oncotic effects duration lasts for 612 hours.

141
 Dextran has been used in extracorporeal circulation as a
volume expander in hypovolemia. Furthermore, it improves
microcirculatory flow by reducing blood viscosity, antithrombotic
(antiplatelet) effects, inhibiting erythrocytic aggregation, and
prevent the adhesion of leukocytes in the microcirculation. The
total dose of dextran infusion must not exceed 1.5 g/kg/day,
because dextran may impair hemostasis (Coagulation
abnormalities may occur due to decreased platelet adhesiveness,
decreased factor VIII). This dose should be further limited in
patients undergoing cardiopulmonary bypass because of used
heparin in these patients. Dextran is used usually in vascular
surgery to prevent thrombosis but is rarely used as a primary
volume expander in cardiopulmonary bypass surgery.
Disadvantages of using dextran as a priming solution:
Anaphylactoid reactions, coagulation abnormalities, acute
renal failure (when renal perfusion is reduced) may occur as
disadvantages of used dextran.
3-Gelatins:
Gelatin is a large molecular weight protein formed from
hydrolysis of collagen when the connective tissues of animals are
boiled (artificial colloids). They have the property of dissolving
in hot water and forming a jelly when cooled.
Gelatins are produced from bovine collagen with an average
molecular weight of 30,000 to 35,000 dalton .There are two
types of gelatins used as priming fluid for cardiopulmonary
bypass: urea-linked gelatin (e.g. Polygeline) and succinyl-
linked or modified fluid gelatins (e.g., Gelofusine, Plasmagel,
Plasmion).
The urea-linked gelatin contains calcium, and thus it should
not be mixed with citrated blood to prevent clot formation, and
plasma calcium concentration may increase as a result of using
urea-linked gelatin as priming solution, and high concentrations

151
of calcium at the end of cardiopulmonary bypass may lead to
coronary vasoconstriction.
Gelatins lead to 70 to 80% volume expansion. But duration
of action is shorter when compared with albumin and starches.
The Advantages of using Gelatins in priming solution for
cardiopulmonary bypass included the low cost of gelatins when
compared with albumin and other synthetic colloids, and they
can be infused without any limit because the are associated
with minimum renal impairment as compared to HMW HES.
Disadvantages: Gelatins are associated with higher incidence
of anaphylactoid reactions as compared to natural colloid
albumin, some studies indicated that there is a negative effect on
blood coagulation (increased bleeding time, impaired platelet
adhesiveness) in patients undergoing cardiopulmonary bypass.
3-Hydroxyethyl starch: Hydroxyethyl starch(HES) is a
synthetic non-protein colloid solution used to treat hypovolemia
, it consists of hydroxyethylated polymers of glucose that derived
from amylopectin.
The different types of hydroxyethyl starches are typically
described by their molecular weight range (Mw), and their
degree of molar substitution (the ratio of replacement of
glucose group by hydroxyethyl group during production). For
example, hetastarch 450/0.7 that means it has an average
molecular weight of (Mw) 450,000 daltons with a molar
substitution of 0.7 . Furthermore , types of hydroxyethyl starch
may be described by its concentration in % (grams per 100ml).
For example, one commercially available hydroxyethyl starch
that is Known as Voluven is described as HES 130 / 0.4 6%.
The characteristics of hydroxyethyl starch (physical and
chemical) are determined by their molecular number (Mn)
,molecular weight range (Mw), and molar substitution ratio.
The molecular number (Mn) of hydroxyethyl starch determines
151
its colloidal effect, hydroxyethyl starch with a higher Mn
contains more numerous starch molecules than the lower Mn
starch, thus it has a higher colloid osmotic pressure than the
starch with a lower Mn. While, the Mw and molar substitution
ratio determines its half-life in vivo. A higher Mw and a more
extensive degree of substitution result in a slower elimination
(half-life 48-67 days in the body and 5-7 days in plasma),
hydroxyethyl starch with a lower Mn and molar substitution
ratio has a shorter half-life(half-life 15-24 days in the body and
1-4 days in plasma) than the starch with a higher Mn and molar
substitution ratio.
The following are some of Hydroxyethyl Starches fluids and
their characteristics:
Hetastarch HES (450/0.7) is the first hydroxyethyl starch,
it was used as priming solution for cardiopulmonary bypass
,available as a 6% solution in isotonic saline. It is safe as
crystalloid priming fluids with a good expansion efficacy .
Compared with albumin as a colloid priming fluid, hydroxyethyl
starch appeared to achieve the similar clinical effects of volume
expansion in patients undergoing cardiopulmonary bypass with
lower incidence of anaphylactoid reactions. Otherwise, retained
the HES (450/0.7) in the reticulo-endothelial system that
associated with an impairment of hemostasis. Oncotic effects of
Hetastarch disappear within 24 h.
Pentastarch HES (200/0.5) is a medium molecular weight
hydroxyethyl starch that was introduced in the late 1980s , it is
available as a 10% solution in isotonic saline. Pentastarch HES
more effective as a volume expander than hetastarch and is more
safe. However, adverse effects of the 200/0.5 starch solution on
hemostasis have also been reported. The oncotic effects dissipate
after 12 hours .

152
 Tetrastarch (third-generation starch) (130/0.4) is low
molecular weight hydroxyethyl starch. It was developed with
an improved metabolic elimination profile, and is safe to be used
as priming fluid to cardiopulmonary bypass circuits ,because it
doesn't have any adverse effects on hemostasis in volumes up to
3 L during the complete perioperative period.
Hextend HES (670/0.75) is a high molecular weight
hydroxyethyl starch solution with high molar substitution,
containing balanced electrolytes sodium, chloride, calcium,
magnesium, and potassium, as well as glucose and lactate. some
clinical reports revealed that Hextend (670/0.75) has a similar
clinical effects as a volume expander when compared with
hetastarch(450/0.7), but it could deliver a favourable metabolic
balance ,with low incidence of blood loss.
The different types of HES vary in their physicochemical
and pharmacokinetic properties, composition, usefulness, and
mostly in their adverse effect. The HES types products should
not be regarded as one homogenous group, and data for one
product should not be extrapolated to another. In particular, the
Tetrastarch (Voluven) 130/0.4 (third generation starch), appears
to offer a combination of safety and efficacy. The synthetic
colloids appear to be the best suited for the treatment of
hypovolemia, and the Voluven seems to offer the best among the
currently available albumin and the synthetic colloids by
comparison with the cost , safety profile, and efficacy.
HES solutions should only be used for the treatment of
hypovolemia (low blood volume) caused by acute(sudden) blood
loss when crystalloids alone are not considered sufficient ,and
patients kidney function should be monitored after HES
administration .Due to the risk of kidney injury and increases risk
of mortality ,do not use HES products including Voluven in
critically ill adult patients, including patients with sepsis
(bacterial infection in the blood) or burn injuries or critically ill
patients.
153
 Table 22: Characteristics of commonly available
colloids
Mw Mn COP Initial Duration Elimination Maximal
volume Effects (Half-life daily
colloid daltons daltons mmHg expansion in plasma) dose \kg

1218 Not
Albumin 5% 69,000 69,000 20-29 80% 2 days
hours Specified

1218 Not
Albumin 25% 69,000 69,000 70-120 200-400% 2 days
hours Specified

Dextran 70 70,000 39,000 58-68 120% 68 hours 45 h 1.5 g

6%
Dextran 40 135-
40,000 25,000 160 200% 24 hours 12 h 1.5 g
10%
succinyl-
linked gelatin Not
35,000 14,000 42 70% 39 hours 2-7 days
Plasmagel) Specified
)3%
Urea-linked
gelatin Not
35,000 15,000 25-29 70-80% 45 hours 2-7 days
Polygeline ) Specified
)3.5%
Hextend HES 670,000 2530 100% 46 hours 5-6 days 20 mL
(670/0.75) 6%
Hespan HES 600,000 2530 100% 46 hours 5-6 days 20 mL
(600/0.7) 6%
Hetastarch 612
HES 450,000 71,000 2530 100% hours 5-6 days 20 mL
(450/0.7) 6%
Pentastarch
HES 264,000 63,000 5560 100-150% 2-12 hours 5-6 days 33 mL
(260/0.45)
10%
Elohes HES
(200/0.62/10) 200,000 60,000 2530 110% 24 hours 6-7 days 20 mL
6%
Hesteril HES
(200/0.5/6) 200,000 70,000 30-37 100% 4-8 hours 3-4 days 33 mL
6%
Lomol HES
(200/0.5/6) 200,000 70,000 59-82 145% 4-8 hours 3-4 days 20 mL
10%
Tetrastarch
HES 130,000 68,000 36 130% 4-6 hours 2-3 days 50 mL
(Voluven)
(130/0.4/9) 6%
Tetrastarch
HES
(Voluven) 130,000 80,000 36 130% 4-6 hours 2-3 days 50 mL
(130/0.4/9)
10%
HES 70/0.5/3 70,000 100% 1-2 days 20 mL
6%

Mw: Weight average molecular weight.

Mn: Number average molecular weight. COP: Colloid Osmotic Pressure.

154
 Select the Correct Priming Fluids
The priming fluids for cardiopulmonary bypass differ from
center to center. There are numerous studies that compare
different types of pump prime. But, until this moment there is no
consensus with respect to the best choice of priming fluids for
cardiopulmonary bypass. Making decision about selection of
priming solution is mainly depending on cost, ease of use,
maintenance of colloid osmotic pressure, and minimum adverse
effects.
Crystalloid solutions are the simple selection of priming
fluids for cardiopulmonary bypass. They are cheaper than
colloids, free of anaphylactoid reactions, and associated with
improved postoperative pulmonary and renal function. But, when
used in large amounts in extracorporeal circuit, the colloid
osmotic pressure may drop as a result of excessive hemodilution.
Low intravascular colloid osmotic pressure may result in the shift
of water from the intravascular fluid to the interstitial fluid,
leading to tissue edema. The normal range of colloid osmotic
pressure is 25 mmHg. During cardiopulmonary bypass, a lower
limit of 15 mmHg can be tolerated without leading to tissue
oedema and organ dysfunction. Decreased priming fluids by used
the newly technologies, such as prime replacement technique
before starting perfusion, the vacuum-assisted venous drainage,
and smaller cardiopulmonary bypass circuit, can eventually allow
to use crystalloid solutions as priming solutions for
cardiopulmonary bypass without lack osmotic activity.
some institutions choose to add albumin into the priming
solution with crystalloids to maintaining the colloid pressure.
Many centers used a combined strategy of crystalloid and
synthetic colloid. Synthetic colloids are inexpensive alternatives
and have similar efficacy to albumin in maintaining the colloid
pressure for cardiopulmonary bypass patients, but may have
some adverse effects on blood coagulation. Many centers used
155
mannitol and sodium bicarbonate routinely as priming additive
. See Table 21.
There are considerable differences between colloids with regard
to their molecular weight (Mw) and their molecular number (Mn).
The Mw determines the viscosity ,the smaller Mw may reduce blood
viscosity and promote blood flow distribution. Whereas, Mn indicates
the oncotic pressure, the larger Mn have greater oncotic pressure.

Table 23: Composition of Commonly Available Priming Fluids

Na + K+ Cl Ca2+ Mg 2+ HCO3 pH Other Osmolarity

Priming
mmol/l mmol/l mmol/l mmol/l mmol/l mmol/l mOsm/L

Dextrose 5% 0 0 0 0 0 0 4.2 Glucose 279

50 g/l

Saline 0.9% 154 0 154 0 0 0 5.0 308

Ringers 131 5.0 111 2.0 0 29(lactate) 6.6 - 280

lactate

Ringers 147. 4 156 4.5 0 0 5.8 - 310

Solution 5

Plasmalyte A 140 5.0 98 0 3 27(acetate) 7.4 294

29(gluconate)

Normasol R 140 5.0 98 0 3 27(acetate) 7.4

29(gluconate)

Bicarbonate 150 0 0 0 0 150 7.0 300

1.26%

Gelofusine 154 0.4 120 0.4 7.1 Gelatin 274

0 0 40 g/l
7.7

Starch 154 0 154 0 4.5 Starch 308

(HES) 0 0
5.5

Human 100 <2 100 <0.1 7.1 Albumin 300

Albumin 4.5 160 160 0 0 citrate 4050
g/l
4.5 Mannitol
Mannitol 10% 0 0 0 0 0 0 100 g/l 620
7.0

156
 Table 23+: The dose of the substances that commonly
additive to priming

20003000 U/L of prime to ensure adequate anticoagulation

Heparin .
(added 4 - 6 U Heparin each 1 ml blood added on priming)

20 mmol/L of prime for Pediatric and 25 mmol/L of prime

for adult ,they are used as buffer when unbalanced priming
solutions are used .
Bicarbonate
(added 4 mmol Bicarbonate each 100 ml blood added on
priming)
Note : Some recent studies have confirmed that there is no
evidence of benefit of sodium bicarbonate use, and wide
range of side effects .

Mannitol Osmotic diuretic and free radical scavenger(0.5-1 g/kg).

Osmolarity: is the number of osmoles of solute per liter of

solution.

157
 Priming Influence in Hemostasis
Both crystalloids and colloids priming fluids may influence
the normal blood coagulation system and hemostasis. These
effects are more apparent when a large volume of priming fluid is
used. As a result of hemodilution some degree of coagulopathy
and impairment of hemostasis may be expected , due to decrease
in the concentration of clotting factors.
The crystalloid fluids influence in hemostasis:
Infusion of a large volume of crystalloid priming fluids (e.g.
above 1 Liter for adult) resulted in a significant increase of
platelet aggregation and a decrease in circulating antithrombin III.
The colloid fluids influence in hemostasis:
Dextrans: are cause a decrease in factor VIII and may
interfere with platelet function, especially at doses above of 1.0
to 1.5 g/kg/day.
Gelatins: The effect of gelatins on coagulation is not clear, it
may cause impaired platelet adhesiveness during the bypass
period and decrease in von Willebrand factor, thus gelatin
impairs the primary hemostasis.
Hydroxyethyl Starch(HES): The negative effects of HES
on Hemostasis is similar to dextran .It include the reduce in
circulating factor VIII and von Willebrand factor (vWF) levels (
vWF is essential to platelet adhesion), reduction of platelet
function, and activated partial thromboplastin time (PTT) and
prolonged bleeding time. The inhibitory effects of hydroxyethyl
starch on hemostasis seem to be associated with its Mw, and its
degree of substitution. A higher molecular weight HES has been
associated with a greater impairment on hemostasis than the
lower molecular weight HES, and the bleeding time will be
greater with higher molar substitution .The third-generation HES
(low molecular weight 130/0.4) has been found to be associated
with better hemostatic profiles than either the high Mn starch or
gelatin when it is used as priming solution for cardiopulmonary
bypass.
158
 Priming Steps for Cardiopulmonary
Bypass Circuits
1. Filling the Reservoir:
A- Check the priming you want to use for sterility, and make
sure their containers are not open or damaged .
B- Fill the Hard-shell Reservoir with priming fluid through the
quick prime port by gravity via any of the filtered inlet ports
located on the top of the reservoir.
C- Heparin should be injected into the reservoir at a rate of
2000-3000 units per liter of the prime to ensure adequate
anticoagulation. If you administer blood with priming add 6
U Heparin to each 1 ml blood added on priming .
D- Add a sufficient prime to the system to maintain a dynamic
priming volume.
E- It is extremely important, that the priming of the oxygenator
and circuit is administered per manufacturer's instructions
for use.
2. Recirculation:
A- Put a clamp on the arterial and venous line after A-V
shunting .
B- Place clamps on either side of the arterial filter (If it was
used).
C- Unclamp the recirculation line between the membrane and
the reservoir.
D- Turn on the blood pump to a slow speed to flush the
priming fluid through the venous reservoir, blood pump,
and membrane (oxygenator).
E- When the circuit appears to be clear of bubbles, the pump
speed should be increased now to remove any bubbles
within the circuit.
F- The reservoir should be inspected for obvious bubbles and
tapped to remove them, and continue de-bubbling from the
151
 outlet of the reservoir, head pump, membranes and
progress to the arterial line , A-V shunt ,to venous line.
G- Close the recirculation line between the membrane and the
reservoir.
H- Stop the pump slowly. Clamp the A-V shunt line.
I- Start the priming for the arterial filter by releasing the
lower clamp(filter outlet), and turning on the blood pump
at slow speed to allow the primer to fill the filter
retrogradely , and discharge air through the purge line .
J- De-air the pressure line .
K- Stop the pump .Release the clamp from the A-V shunt line.
L- Release the top clamp on the filter(filter inlet).
M- Clamp the arterial filter bypass loop.
N- Start the pump at high speed . Invert the filter and tap to
remove bubbles.

3. Priming the A/V Loop

A- Stop the blood pump.
B- Clamp the A-V shunt line.
C- If necessary, add more priming fluid to the venous
reservoir.
D- Unclamp the venous line. Unclamp the arterial line.
E- Set occlusion of the arterial pump (if a roller pump is
used) before priming the A/V Loop. (See Occlusion
Settings In Page 163)m
F- Start the blood pump gradually.
G- When all air is purged from the A/V loop, slowly increase
blood pump flow to high speed, and recirculate the
priming fluid through the entire circuit.
H- Partially occluding the venous line is recommended to
offer resistance, to provide a positive pressure( around 80
mmHg) during recirculating the primer, to remove any
bubbles from the membranes and filters.

161
 I- Before cutting the circuit by the scrub nurse, a final check
must be done by both the perfusionist and scrub nurse for
the presence of bubbles.
Note: Before priming, a CO2 flush is recommended to displace air and
reduces the risk of gaseous emboli.
Note: Pre-cardiopulmonary bypass filter use, is a recommended by the
manufacturers to remove particulate contamination from the circuit.

Warning: All gas emboli must be cleared from the extracorporeal circuit
before beginning bypass. Gas emboli are dangerous to the
patient.

Warning: During recirculation do not use pulsatile flow, and do not stop
the pump suddenly. Otherwise gaseous emboli may enter from
gas phase due to inertia force.

4. Pre-warm the Priming Fluid

A. Start heat exchanger water flow to pre-warm the priming
fluid.
B. Inspect the entire system for leaks.

5. Priming cardioplegia if demanded:

A- Check the vials of cardioplegia before injecting in 500 ml
normal saline 0.9% bag.
B- The bags must be labeled clearly with the date ,concentration
,and name of the person who prepared it, immediately after
preparation.
C- Turn on the cardioplegia pump slowly to prime the
cardioplegia circuit with NaCl 0.9%.
D- When the circuit appears to be clear of bubbles, the pump
speed should be increased to remove any bubbles within the
circuit.
Warning: Make sure that the flow of arterial pump is always higher
than the flow of cardioplegia pump.
E- Check the cardioplegia pump calibration, and make sure it is
correctly programed into the pump console .
161
6. Priming a centrifugal pump if demanded:
A- Clamp the outlet tube of the venous reservoir .
B- Prime the reservoir.
C- Release the clamp on the outlet tube slowly to allow the
prime to fill the cones of the centrifugal head slowly( by
gravity).
D- Check the cones for bubbles and if bubbles are found ,they
should be let out of the inlet port back into the venous
reservoir .
E- Insert a bi-directional flow probe into the arterial line.
F- Turn on the centrifugal head motor gradually ,and circulate
the priming fluid through the entire circuit.

162
 Occlusion Settings
Roller pump occlusion should be set before bypass ,to ensure
accurate delivery of systemic blood flow.The roller head pump
occlusion (degree of compression) is determined by the
separation region between the rollers and the backing plate, it is
set by adjusting the distance between the raceway and each of the
roller heads, which control the cross-sectional area inside the
tubing at the point of compression by the roller head.
The occlusion must be properly set, to minimize hemolysis
and prevent backflow through the roller head. Total occlusion is
not used because greater degrees of occlusion cause increased
hemolysis, spallation, and excessive tubing wear. Furthermore,
too little occlusion can lead to increased hemolysis due to the
presence of a large area between the pump head and the backing
plate that causes a rapid regurgitate backflow causing large-
velocity gradients and excessive red blood cell shear stresses .
Too little occlusions can also lead to decreased forward flow to
the patient.
1: Occlusion of the arterial pump if a roller pump is used:
First method:
A- Close the sampling ports and any re-circulating lines.
B- Hold the distal arterial line vertically .
C- Advance a column of priming approximately 30 cm above
the level of the pump.
D- Deocclusion of (Removal the previous occlusion) the rollers
by moving the rollers away from the backing plate to ensure
there are no excessive occlusion .
E- Adjusting roller occlusion against the backing plate to allow
slight drop of fluid at a rate less than 1 cm /min .The
occlusion should be set to each roller separately (one by
one) , If one of the rollers in the pump head does not yield
the same rate of fluid drop(underocclusion), the occlusion
should be set to the roller that is tightest.
163
Second method:
A- Clamp the arterial line and any re-circulating lines and close
the sampling ports .
B- Turn the pump carefully until the pressure on the gauge is
around 300 mmHg.
C- Observe the rate of pressure drop.
D- Tighten the occlusion until there is no drop of pressure in
this pressure range (Ensure that there are no other leaks in
the circuit and that all clamps are competent).
E- Adjust the occlusion until the drop off of the pressure over
the lower 260280 mmHg range takes approximately 10
seconds.
F- The occlusion should be set to each roller individually. If the
occlusion between both rollers is clearly unequal , the pump
should be changed.

Warning:
Premature tubing failure may occur if the rollers are excessively
occluded .
Do not lubricate pump headers with silicone or silicone grease
.failure may result due to swelling and weakening of the silicone
tubing.

2: Occlusion of the suction pumps:

A- A clamp is placed on the tubing on the inlet side of the
sucker roller pump and gradually occlude the rotating rollers
until the silicone tubing within the pump head is collapses.
B- Decrease the occlusion until the vacuum is cleared.
C- The occlusion setting is then again increased, until the
vacuum is just drawn and held.

164
 If the raceway tube in the rollers pump is made of PVC
material, the collapse of the tube is difficult due to the
resilience of PVC tubes, and requires more than usual of
occlusion. Excessive occlusion causes increase hemolysis,
increase tube spallation, and increases the load on the head
pump. Therefore, the occlusion not done by collapse but by
pulse, a clamp is placed on the tubing on the outlet side of the
sucker roller pump, and then put your finger on the line
(between the outlet of head pump and the clamp) and
gradually occlude the rotating rollers until you feel the
pulse of the tube on your fingers.

165
 Anticoagulants for CBP
Coagulation (clotting): is a complex process by which blood
changes from a liquid to a gel (clots). It is an important part of
hemostasis (the stopping of blood loss from a damaged vessel).
The mechanism of coagulation includes platelets activation
(adhesion, and aggregation) to seal a damaged blood vessel wall,
and clotting factors responding to form fibrin which strengthen
the platelet plug and begin repair of the damaged vessel.
There are two ways of fibrin formation, the tissue factor
pathway (extrinsic pathway), and the contact activation pathway
(intrinsic pathway). The extrinsic pathway begins with trauma
to the tissues outside the blood vessels, whereas the intrinsic
pathway begins with trauma to the blood itself when it comes
into contact with damaged or roughened vessel walls. Then both
pathways result in the activation of factor X that converts
prothrombin to thrombin with help from factor Xa. Thrombin
converts fibrinogen to first soluble fibrin, which is then made
insoluble by the activation of Factor XIII. View Figure 5:1.

166
 Heparin
The heparin is an anticoagulant discovered in 1916, it was
isolated from liver cells, hence the name (heparin) from the
Greek "hepar", which means liver.
After many years the manufacturers extract the heparin that
is safe for intravenous administration. The commercial heparin
most often derived from pigs intestinal mucosa (porcine mucosal
heparin) and lung heparin from cattle lung (bovine lung heparin).
Both bovine lung heparin and porcine intestinal heparin have
been widely used as anticoagulants for CPB. But some studies
show that the lung heparin have a slight advantage for CPB
anticoagulation.
Heparin: is a compound of highly sulfated polysaccharide
located in mast cells , and has the highest negative charge density
of any known biological molecule which is strongly acidic, and is
widely used as an injectable anticoagulant . View Figure 5:2 .

Heparin: was used in cardiopulmonary bypass as an

anticoagulant, because of its clinical effectiveness as an
anticoagulant; it is rapid, and can be rapidly neutralized by
protamine. Inhibition of microvascular coagulation is important
to prevent clotting ,and decrease the inflammatory response for
cardiopulmonary Bypass, and reversal of this effect is important
for hemostasis at the end of cardiopulmonary bypass.

167
 Mechanism of Heparin Action
The mechanism of heparin action is to prevent thrombin
formation, by increasing the activity of the antithrombin factor
(AT III), to inhibit transformation of prothrombin to thrombin
through inhibition of factors IIa (thrombin) and Xa.
Antithrombin Three Factor (AT III): is glycoprotein found
in plasma. heparin binding with AT III leads to increase in the
ability of AT III to inhibit thrombin to 1,000 times or more
.Longer heparin chains effectively inhibit II a and Xa, whereas
shorter heparin chains preferentially inhibit Xa. View Figure 5:3.

Heparin is also associated with the second helper factor

(cofactor II), cofactor II is a glycoprotein that can cause
inhibition of thrombin independently of the ATIII. This reaction
occurs slowly and requires larger doses of heparin compared with
AT III. Heparin association with cofactor II is important for
anticoagulation, especially in patients with AT III deficiency .
168
 Heparin Dosing
Determination of the adequate dose of heparin is crucial.
Inadequate dosing of heparin leads to inadequate anticoagulation.
Inadequate anticoagulation may cause thrombosis, intravascular
clotting, oxygenator dysfunction, and consumption of clotting
factors .The initial dose of heparin in an adult patient has been
determined by the patient's weight.To calculate heparin doses in
milligrams (mg) based on patient's weight:

Adult Heparin dose = 3 weight in Kg.

Anticoagulation can be more difficult to manage in neonates

and infants, due to the coagulation abnormalities that are existent
in neonates and infants, especially in deeply cyanotic patients.
The AT III concentration in healthy newborns is only half that of
adults. Using a standard dose (Adult doses) of heparin may result
in inadequate anticoagulation and intravascular coagulation. The
dose of heparin that delivered to pediatric patients should be
more than adult, because of the deficiency of antithrombin III
(AT III) in pediatric patients. They also have a higher volume of
distribution(VD); and hence require higher doses of heparin
based on the body weight .

The initial doses of heparin in pediatric patients in mg

determined by the weight or body surface area of patients. To
calculate heparin doses in mg for pediatric:

Pediatric Heparin dose = 4 weight in Kg or

Pediatric Heparin dose = 90 BSA.

Administration of fresh-frozen plasma or recombinant AT III

remedies the low concentration AT III if required. Some
pediatric patients present with unusual hematologic problems,
161
such as protein C deficiency, that can greatly increase
coagulation risk during cardiopulmonary bypass without careful
management of anticoagulation. The half-life of IV heparin is
relatively short (from 60 to 90 min), so a maintenance doses of
50 to 100 U/kg given as often as every 60 minutes.

Extracorporeal circuit Heparin doses usually from 2000

to 3000 IU per Liter of priming fluid, or 1 mg per
kilogram. (1mg Heparin = 100 IU )

Side Effects of Heparin

The most common side effects of heparin are a bleeding
complications. Large doses of heparin induce platelet
dysfunction (abnormalities of hemostasis), stimulation of tissue
factor pathway inhibitor, facilitation of fibrinolysis, probably
increases surgical bleeding, and a decrease in systemic vascular
resistance (hypotension can occur if given rapidly). Several CPB
bleeding complications are related to heparin, higher
cardiopulmonary bypass heparin concentrations predisposed to
postoperative heparin rebound effect, that requires treatment with
additional protamine. Residual unneutralized heparin or heparin
rebound can cause excessive postoperative bleeding after CPB.
It seems unwise to exceed the activated clotting time
(ACT) value of 600 seconds, because the excess
anticoagulation can results in excessive bleeding and a risk for
intracranial hemorrhage.

171
 Perioperative Abnormal Coagulation

Perioperative abnormal coagulation can occur due to many

reasons:

First: Decrease in coagulation factors during CPB and into

the postoperative period due to hemodilution, and consumption
of coagulation factors by activation of the extrinsic clotting
system during bypass.

Secondly: a quantitative and qualitative platelet defect,

results from platelet activation that produced from initial contact
with the artificial surfaces of the circuit and oxygenator .

Finally: Cardiopulmonary bypass results in an alteration of

normal fibrinolytic and antifibrinolytic processes. During and
throughout the first 24 hours after the CPB, there is an elevation
of tissue plasminogen activator (fibrinolytic state exists).

171
 Monitoring the Activity of Heparin
There are number of tests that we can use to monitor the
activity of heparin. These tests fall into two categories, heparin
effect "the activated clotting times" (ACT), and measurements
the heparin concentration in blood or plasma .
1- The Activated Clotting Times(ACT): ACT has been
used as the standard test by many centers because it is not
expensive and very simple to use . But because of the
hemodilution and hypothermia during CPB ,the sensitivity of the
ACT to heparin is increased ,and this test becomes inaccurate.
A normal ACT before heparin administration is in the region
of 110-120 seconds. During cardiopulmonary bypass ACT
should be maintained at greater than 480 seconds to minimize
the risk of intravascular coagulation , which is caused by
exposure of coagulation factors to the foreign surfaces of the
bypass circuit.
The ACT minimum of 300 seconds has withstood the test of
time in some clinical reports without formation of clot in the
oxygenator circuit, but there is no apparent advantage to
maintaining ACT below 400 seconds, and achievement of ACT
above 480 seconds before initiating CPB is recommended by
many studies ,to provide a safety margin . Lower ACTs may also
be acceptable with heparin-coated circuits, the simplest clinical
guideline is to exceed ACT value 400s during CPB for cardiac
surgery, and a minimum ACT of 180 seconds had been suggested
for patients undergoing long-term extracorporeal oxygenation for
pulmonary support( ECMO).
The perfusionist must regularly(Every half hour) measures
the ACT level to maintain it at greater than 480 seconds, Because
the heparin is metabolized during cardiopulmonary bypass.

172
 2- Heparin Concentration: The most commonly used method
to measure the heparin concentration in plasma or blood is the
automated protamine titration method. Both heparin and protamine
doses are calculated based on the patient's blood volume. Protamine
titrations measure heparin concentration by identifying the reagent
concentration that optimally neutralizes heparin, judged by the fastest
clot formation under standardized conditions; so the tube or cartridge
with the shortest clotting time represents the closest match between
heparin and its neutralizing agent. This information can be converted to
heparin concentration because the neutralization ratio of protamine to
heparin is known (usually 1.0 to 1.2 mg of protamine to 100 U of
heparin).

Heparin concentration in whole blood on cardiopulmonary

bypass must be maintained greater than 4.0 U/ml. The
maintenance of a stable heparin concentration usually results in the
administration of larger doses of heparin than those given with ACT
monitoring because hemodilution and hypothermia during CPB
increase the sensitivity of the ACT to heparin. Automated heparin
concentrations generally remain stable with hypothermia and
hemodilution but do not measure the degree of anticoagulation. The
measuring heparin concentration alone may fail to detect patients who
are markedly resistant to heparin-induced anticoagulation.

It has not been clearly established whether it is better to monitor

heparin concentration or heparin effect, but in one of the patients who
had a previously undiagnosed familial deficiency of AT III ,the clots
were reported in the surgical field and the extracorporeal circuit
despite maintenance of whole blood heparin concentrations of 4.0
U/mL or higher. The ACTs were not reported for that patient. This
clinical scenario could have been avoided by monitoring heparin
effect (ACT) rather than heparin concentration .In summary, we
cannot use a heparin concentration test instead of the ACT in CPB,
but if we use a heparin concentration test must be use along with
ACT. An advantage of the ACT test is that it is a bedside test, and
can be done easily in O.R. or ICU after surgery.
173
 Anticoagulation Management in CPB
1- Administer heparin 300 U/kg for adult ,and 90mg BSA for pediatric
patients intravenously by anesthetist.
(The Perfusionist have added heparin to CPB circuit prime at a dose
approximately 2- 3 U/ml).
In emergency case there is need to institute immediate CPB, so it
reasonable to give a large systemic dose of heparin (400 U/kg) for
adult because there may be insufficient time to confirm the effect of
heparin with an ACT. Under these circumstances, it also seems
reasonable to place a larger-than-usual heparin dose in the
extracorporeal circuit (e.g., 10,000 U for a usual adult priming
volume).
2- After 3 to 5 minutes from heparin administration take an arterial
sample for ACT.
3- If the ACT is less than the target range give additional heparin as
needed to achieve an ACT above 400 seconds before initiating CPB
and to maintain an ACT above 480 seconds during CPB. If the
resulting ACT is still < 480 seconds, then the surgeon and
anesthesiologist should be consulted on the possible diagnosis of AT3
deficiency. If this diagnosis is reached, then 1-2 single donor units of
plasma should be ordered, and either administered before CPB by the
anesthesiologist or added to the pump prime by the perfusionist. If the
surgeon wants to start CPB before the administration of plasma, the
perfusionist should discuss the adequacy of anticoagulation with him
and explain the danger of proceeding and initiation of CPB in such
patient (oxygenator failure, DIC, ). Alternatives to heparin should
be discussed(if available), such as bivalirudin, lepirudin,
danaparoid or argatroban. These alternatives were all used
successfully in different situation, such as allergy to heparin or in
patients known to have heparin-induced thrombocytopenia (HIT).
4- Monitor the ACT every 30 minutes during CPB, or more frequently
if the patient proves resistant to heparin-induced prolongation of the
ACT.
5- If ACT decreases below the desired minimum value, supplemental
heparin doses of 50 to 100 U/kg most often sufficient to prolong
the ACT without the aid of precise calculations. Otherwise, by
Heparin concentration test, we can measure the dose of heparin, which
must be given to reach the desired concentration of heparin.
174
 Heparin Resistance
Heparin resistance: is need for higher-than-normal heparin
doses to induce sufficient anticoagulation(above 480 seconds) for
the safe conduct of CPB.
Many numerous factors have been reported to alter the
anticoagulation response to heparin. In most cases, heparin
resistance can be adequately treated with increased doses of
heparin. But in some cases ,the increased of heparin dose not
enough, and there is necessity for other interventions.
Reasons of Heparin Resistance in Clinical Situations:

1- familial AT III deficiency.

2- Ongoing heparin therapy (induced thrombocytopenia).
3- Extreme thrombocytosis (platelet count >700,000/L).
4- Septicemia.
5- Eosinophilia syndrome.
6- Antiphospholipid Syndrome.
The most diagnosed cases of heparin resistance in patients
about to undergo cardiopulmonary bypass is the Antithrombin
III deficiency. To overcome this heparin resistance, fresh frozen
plasma (which contains normal concentrations of AT III) or AT
III concentrate will be given to increase AT III. Fresh frozen
plasma is a less expensive source of AT III, but it carries the risk
for infectious complications. The AT III concentrate also has the
advantage of small volume (few milliliters), which can be given
in few seconds, without exposing patients to risks of blood
product transfusion. FFP also needs at least 15 minutes to melt,
while AT III can be given immediately.
Otherwise, If the AT III deficiency not treated, very high
doses of heparin must be given to overcome heparin resistance,
with caution from bleeding diathesis that can result from
fibrinolysis, platelet dysfunction, or heparin rebound.
175
 Reversal of Anticoagulation
One of the advantages of heparin is that it can be easily
neutralized by Protamine.
Protamine: Is a protein derived from salmon sperm, it is a
strongly alkaline compound, contains many positive ions.
Positive ions in the protamine attract negative ions in the
heparin(to produce a stable precipitate), sufficiently to separate it
from its binding site on ATIII and reverse its anticoagulant
effect. View Figure 5:3.

Protamine contains two active sites, one that neutralizes

heparin and another that exerts a mild anticoagulant effect
independently of heparin .Some researchers believe that this
anticoagulant effect of protamine is not clinically important
except in the case of using dose exceeding three times those
doses used to neutralize heparin. The anticoagulant effect of
protamine may be attributable to inhibition of platelets, and
induced decrease in platelet aggregation.

176
 Calculation of Protamine Dose
Accurate calculation of the protamine dose is important because
unneutralized heparin can increase postoperative bleeding .The dose
of protamine needed may decreases with time due to the continuous
metabolism to heparin in the body (the half-life of heparin is 60-90
minute) . Improper protamine dose may result in inadequate reversal,
protamine anticoagulation, or adverse side effects.

Methods for calculating the protamine dose:

Fixed Protamine Dose Method: Use a fixed ratio of protamine to
the total or initial dose of heparin. This method involves giving 1.0 to
1.2 mg of protamine for each 100 U of heparin. The main advantage
of this method is simplicity. The disadvantage of this method is the
considerable variability in the half-life of heparin, that makes it
difficult to predict the status of the coagulation system immediately
preceding heparin neutralization.

Protamine Titration Method:Calculation of protamine dose

methods used tubes with several dilutions of a standard protamine
solution, a fixed volume of whole heparinized blood is added to
these tubes , the lowest protamine concentration resulting in the
shortest clotting time is represents the optimal neutralization of
heparin. The protamine dose is then calculated based estimated blood
volume.

The protamine dose can be used to calculated heparin concentration

(neutralization ratio of protamine to heparin is known). Therefore, this
method is actually an indirect way of estimating heparin
concentrations.
Advantages for this method: 1-Administration of a lower protamine
dose than with a fixed-dose method. 2-Absence of excessive
postoperative bleeding response ,and heparin rebound despite reduced
protamine doses.
177
 Side Effects of Protamine
One of the side effects of protamine is inhibition of plasma
coagulation and platelet function, so it appears prudent to avoid
administering protamine doses more than the amount that needed
to neutralize heparin. In most patients an excess protamine dose
of 1 to 2 mg/kg will be probably tolerated without adverse effects
on hemostasis. However, that protamine overdose can lead to
further platelet dysfunction lasting several hours into the post-
bypass period.

Protamine Reactions
Protamine reactions can be classified to:

1- Pharmacologic Histamine Release:

Histamine release is principally related to rapid

administration of protamine and can result in bradycardia,
vasodilation, sudden fall in blood pressure, pulmonary
hypertension, and possibly myocardial depression.
2- True Anaphylaxis ( IgE-mediated):
True anaphylaxis can result from previous exposure to
protamine, which is demonstrated only in diabetic patient who's
taking intermediate duration insulin preparations that contain
protamine. Even in that patients group , the anaphylaxis
incidence after protamine administration is low in most studies
(<3%).
3- Anaphylactoid reactions( Non . IgE-mediated).

178
 Normal Coagulation Values
Table 24 : Normal Coagulation Values
Activated clotting time(ACT) 110-120 seconds
Prothrombin time (PT) 10-14 seconds
Partial thromboplastin time (PTT) 25 - 35 seconds
Thrombin time (TT) less than 15 seconds
Bleeding Time 1 - 9 minutes
International Normalized Ratio (INR) 0.8 - 1.2
Fibrinogen Level 200 to 400 mg/dL

171
181
 Pre-Bypass Conduct
1. Start with the posting of the operating list:
Perfusionist must assemble specific information about the
scheduled procedure : Surgeon, patients data, laboratory
results, diagnoses, procedure and time of operation.

2. Review the patients hospital file:

Recording patient data on the perfusionist data sheet.

3. Homodynamic calculations (e.g. BSA, cardiac index, and

blood flow).

CPB flow (Q) = CI BSA.

BSA : Body Surface Area.

CI : Cardiac Index.
CO : Cardiac Output.
CPB : Cardiopulmonary Bypass.
Q : Blood Flow .
MAP : Mean Arterial Pressure.
CVP : Central Venous Pressure.

You can calculate the body surface area also by using the
following diagrams .
181
182
To determine body surface area, draw a straight line
between the height and weight ,the point where the
line crosses with body surface area scale, indicate to
patients body surface area.
For example, for a subject 170 cm tall and weighing 67
kg, body surface area will total 1.80 m2 .

Estimating Body Surface Area According Patient

Weight

183
 To determine body surface area, draw a straight line between
the height and weight ,the point where the line crosses with body
surface area scale, indicate to patients body surface area.
For example, for a subject 170 cm tall and weighing 67 kg,
body surface area will total 1.80 m2.

184
 In case of emergency we can estimate the body surface area
according patient weight as shown in the following table(28) .

Table 28: Patient Weight and the Average of Body

Surface Area
Patient Body Surface Patient Body Surface
Weight Area Weight Area
0.8 0.08 22 0.85
1.0 0.10 24 0.90
1.5 0.14 26 0.95
2 0.16 28 1.00
2.5 0.18 30 1.05
3 0.20 32 1.09
3.5 0.23 34 1.14
4 0.26 36 1.19
4.5 0.28 38 1.23
5 0.30 40 1.27
5.5 0.33 42 1.32
6 0.35 44 1.36
7 0.38 46 1.40
8 0.42 48 1.44
9 0.46 50 1.48
10 0.49 52 1.52
11 0.53 54 1.56
12 0.56 56 1.60
13 0.59 58 1.64
14 0.62 60 1.68
15 0.65 65 1.76
16 0.68 70 1.84
17 0.71 75 1.90
18 0.74 80 1.95
19 0.77 85 2.05
20 0.79 90 2.15

185
4. Selection type and size of Oxygenators. (See Page 114) .
5. Selection of the disposable perfusion circuit and
equipment by using existing protocols.
6. Calculate priming volume, Drug dose (Heparin, Sodium
Bicarbonate, Mannitol).
7. Calculate patients blood volume.
Table 29 : Patients Blood Volume based on Weight:
Patients Weight Blood Volume
>10 Kg 85 ml/kg
10-20 Kg 80 ml/kg
21-45 kg 75 ml/kg
Male 70 ml/kg
Adult female 60 ml/kg

8.Predicted hematocrit on initiation of CPB.

The initial hematocrit on bypass can calculate by two formulas:
A- The volume concentration formula .

V1: blood volume patient. V2: total volume on bypass.

C1: patient hematocrit. C2:Initial hematocrit on bypass.

B- The initial hematocrit formula .

Red cell volume = EBV pre CPB HCT .

System volume = EBV + CPB prime volume + Prebypass IV fluid.
EBV: Estimated blood volume of patient .

186
9. Calculate transfused blood volume if need to reach to
target of hematocrit.

TBV : Transfused Blood Volume ( ml).

HT : Target hematocrit during pump.
HT2 : Preoperative hematocrit .
CV : Circulating volume of patient .
CPBV : Priming volume in the CBP circuit .
HT TBV : Hematocrit of transfused blood (40).

10. Connect your heart lung pump machine ,heater cooler

machine to electricity.
11. Assembly of the cardiopulmonary bypass circuit.
12. Priming the oxygenator.
13. Monitoring Safety device on.
A- Pressure monitoring: Warnings and pressure limits
must be set by perfusionist.
B- Level sensors: The level sensor must be positioned
at minimum operating level on the reservoir. Level
sensors should be set to slow the pump down before
stopping it, if that option is available.
C- Bubble detectors: for patient safety the use of air
bubble detector is a must to avoid any air bubbles
from entering the vascular system, those detectors
are placed in the circuit post-arterial filter, these
detectors having the ability to stop the pump. See
Table 30.

187
 Table 30 :Monitoring Components of the CPB and
its Function
Monitoring device Function

Pressure monitoring Alarms when line pressure exceeds

set limits.
Level sensors When level in the reservoir arrives to
safety level .
Bubble detector Alarms when bubbles are sensed.

14. All gas emboli must be cleared from the extracorporeal

circuit before initiating bypass.
15. Make occlusion for all roller head pumps.
16. Cardiopulmonary bypass Positioning.
Some surgeons prefers placing that the pump opposite them
on the patient's left side, while others prefers positioning the
pump on the patient's right side directly behind them, the
pump may also be positioned at an angle to the patient .
Wherever the chosen position, the perfusionist shall place the
pump near the operating table to minimize tubing lengths,
resulting in decreasing required priming volume.
17. Pre-CPB safety concerns
Heparin given, activated clotting time (ACT) >480
seconds.
o ACT>200sec you can start cannulation.
o ACT>300sec you can start cardiotomy suction.
o ACT>400sec you can start CPB.
Arterial Cannula correctly placed.
Shunt lines are clamped.
No clamps on the arterial or venous lines placed by
surgical team.
Vasopressors prescribed and available.

188
 18. Controlling Perfusion Parameters
a. Oxygen Transfer:
Transfer is controlled primarily by concentration of O2 in
the ventilating gas.
Increase the O2 concentration to raise the patients arterial
pO2, and decrease the O2 concentration to lower the
arterial pO2.
b. Carbon Dioxide Transfer:
Carbon dioxide transfer is controlled by gas flow rate.
Increase the gas Flow rate to increase the amount of CO2
removed from the blood, decrease the gas flow rate to
decrease the amount of CO2 removed from the blood

Normal Range and Blood Products Information

Table 24: Normal Blood Gas on Cardio Pulmonary Bypass
Normal Arterial Blood gas on CPB Normal Venous Blood gas on CPB

PH 7.35-7.45 PH 7.35-7.39
PO2 120-200 mmHg PO2 38-42 mmHg
PCO2 35-45 mmHg PCO2 44-48 mmHg
O2 sat 96-100 O2 sat 73-77
BE 0 BE -2.5 - 2.5
Bicarb 22-28 mEq/L P50 27

Table 25 : Normal Electrolytes

Sodium 136-145 mEq/L
Potassium 3.5-5.3 mEq/L
Chloride 100-106 mEq/L
Calcium 8.5-10.5 mg/dl
Phosphorus 3-4.5 mg/dl
Magnesium 1.5-2.5 mEq/L
Other
Glucose 70-130 mg/dl
Serum Osmolarity 285-295 mOsm/L

181
 Table 26: Blood Products Information
Component HCT Volume Storage Time
RBC 70 300 ml 35 days
WB 40 300-500 ml 35 days
WB ,heparinized 40 300-500 ml 48 hours
Platelets n.a 30-50 ml 3 days
Fresh-Frozen Plasma n.a 220 ml 1 year

Pre-Bypass checklist
Power cable secure.
Backup power available.
Hand cranks available.
Backup light source available .
Patient data entered.
Oxygenator perfectly place on holder and secure.
Water lines connected.
Water heater-cooler operable and warming.
Oxygenator checked for leaks (before priming).
Remove the vent cap.
Gas supply operational and blenders working.
Gas line connected and not leaking and obstructed.
Pump circuit tubing secure without kinks.
Luer connection tight.
Suckers and vent (sump) in proper direction.
Occlusion set on roller pump.
Arterial filter primed.
Cardioplegia system primed and at proper temp.
Cardioplegic solutions is ready.
Pressure line is de-airing .
Pressure transducers calibrated.
Level sensor operable.
Bubble detector operable.
Temp probes connected.
Supply and backup components available.
Tubing clamps available.

111
 Pre-bypass Checklist

Patient Name: _________________________________

HOSPITAL NO:_______________________________
Disposables Components: Monitoring
o Package is not open or o Temperature probes connected.
damaged. o Pressure transducers calibrated.
o Expiry date. o Sensors calibrated.
o Sterility
Safety devices
Heart-lung machine o Low-level alarm operational.
o Power connected. o Air detector operational.
o Start-up normal. o Pressure alarm limits set.
o Battery(Back-up power) is o Temperature alarm limits set.
ready.
De-airing
Heads Pump
o Tubing .
o Roller heads power on .
o Oxygenator .
o Flow meter:
o Arterial filter .
calibration(LPM\RPM).
o Pressure lines .
o Occlusion & direction.
o Cardioplegia .
o Roller heads smooth & motors
quiet. Cardioplegia .
o Solutions ready.
Oxygenator
o Ratio set accurate .
o Cardiotomy reservoir vented.
o Stop linked to arterial head.
o Gas line attached.
o Heat exchanger leak tested. Accessories
o Tubing clamps .
Heater-cooler
o Solutions & drugs available.
o Start-up normal.
o Syringes & connections available.
o Water level adequate .
o Hand cranks available.
o Water temperature accurate.
o Backup circuit components .
Gas supply
o Gas lines connected. Anticoagulation
o Flow meter and blender functional. o Heparin in: _______time .
o Hoses leak free . o ACT _____ .
o Gas filter patent .
o Circuit CO2 flushed . Ready to start bypass .
Tubing
o Pump tubing condition
inspected.
o One-way valves in a correct Signature:
direction.
o Circuit shunts closed.

111
 The CBP Communication Team
1- Surgeon.
2- Anesthetist.
3- Perfusionist.
4- Scrub Nurse.

Ultimately the surgeon is directly responsible for

patient outcome, but for the final success of the procedure we
need full communication between all members of the team.

Determines the planned operation, target perfusion

temperatures, methods of cardioplegia, cannulation and
special perfusion as cerebral flow.
Communicates procedural steps:
Connecting Disconnecting CPB, perfusion management
and surgical exposure .

Anesthesia.

Given anticoagulation before CPB and anticoagulation

management during the operation .
Troubleshooter of complex procedures along with the
surgeon.
Communications with perfusionist after pump off to
loading patient by the residual blood in pump circuit.
112
 Setting up and priming the CPB machine .
Safety checks and monitoring anticoagulation.
Adding some specific drugs .
Maintaining records.
Constantly monitors the cardiopulmonary bypass machine
and the extracorporeal circuit.

Communications with perfusionist before procedure to

chosen cannulas, and to know about any special connection
procedure the perfusionist need to do.
Connects lines between table lines and pump lines in a
sterile technique.
Make sure no bubble in the table pump line .

Put clamp on venous line and arterial line, then can cut
lines and connects the cannulas .
Open venous line after pump off to tack blood by
perfusionist.

113
 Starting Cardiopulmonary Bypass
1. Scrub nurse: Lines connects between table lines &
pump lines in a sterile technique.
2. Surgeon: Heparin in.
3. Anesthesiologist: Give heparin and ACT check.
4. Perfusionist: Increase flow speed fast circulating the
priming solutions, make sure no bubble stay.
5. Perfusionist: Stop flow and put clamp on venous line,
(you must put another clamp on arterial line if
centrifugal pump used) then scrub nurse can cut lines.
6. Surgeons prepare to do cannulation.
7. ACT > 300 sec (three minutes after heparin given)
Pump suckers on.
8. After the aortic cannula inserted in aorta and
debubbled
9. Surgeon say: Flush.
10. Perfusionist answer: Flushing ( do slowly flushing).
11. Surgeon: Stop flushing .
12. Perfusionist: Ok, Stop flushing sir .
13. Surgeon: Arterial cannula clear and open .
14. Perfusionist answer: Ok, testing the cannula sir.
(makes sure that the arterial line pressure is equivalent
of main arterial pressure, and correlates with the
arterial pressure waveform "pulsatile swing on a
pressure gauge". Give proportional volume to flow of
the patient with observe the arterial line pressure,
while you giving that volume the ALP must be less
than 100 mmHg).
15. Perfusionist: Oxygen on.
16. ACT > 480 ready to on bypass.
17. Perfusionist: Venous saturation monitoring on.
18. Surgeon: Pump on.
19. Perfusionist: On bypass sir, Timer on.

114
20. Anesthesiologist: All IV fluid lines should be turned off.
This is to prevent. hemodilution.
21. Perfusionist: Start flow slowly, open the venous tube,
and slowly go to full flow. Continuous Monitoring on
CPB:
a. Reservoir level.
b. Pressure line.
c. Deferent between venous and arterial color.
d. Blood pressure.
e. Flow rate .
f. ECG.
g. venous oxygen saturation 65%-75%.
22. Surgeon setting the cannula of Cardioplegia (ante
grade - retrograde).
23. Perfusionist: Start Cooling.
24. Communication between surgeon and perfusionist.
25. Anesthesiologist: should be assessing the patient by
checking for responsiveness periodically. especially
when overt signs of insufficient anesthetic depth are
present, such as patient movement and hemodynamic
changes. (nitrous oxide is never used during CPB since any
air emboli would quickly enlarge and potentially cause a
significant air embolism).
26. Perfusionist: Continuous monitoring during CPB:
a. Reservoir level.
a. Pressure line/arterial line pressure.
b. Blood pressure/patients:
Adult patient arterial pressure 50-90 mmHg.
Pediatric patient arterial pressure 20 70 mmHg.
c. Oxygen saturation.
d. Temperature appropriate.
e. ECG.
f. Venous oxygen saturation 73%-77%.

115
27. Conduct Trouble during Cardiopulmonary Bypass. See
Table 31.

Table 31 :Safety concerns during CPB

Trouble Make Trouble
Small size of venous cannula.
Impaired venous return (compression on heart
Low level alarm on venous by surgeon, table on low position).
reservoir Tubing kinked.
Air lock.
Hemorrhage.
Major Bleeding .
Misplaced venous cannula.
Clotting within circuit.
Small size of aortic cannula.
High-pressure alarm on Clamping or kinking of line.
arterial line Manipulation of the aorta.
Clotting within circuit.
Aortic dissection.
Bubble alarm Air in line.
Sensor malfunction.
Inadequate blood flow.
Low mixed venous oxygen Hemorrhage.
saturation Shunt clamp unintentionally removed.
Excessive hemodilution .
Poor blood gasses despite
adequate gas delivery, and Oxygenator failure.
pump flow

28. Perfusionist: Other Monitoring During CPB:

Blood gasses. Electrolytes.
ACT > 480 sec. Blood sugar.

29. Perfusionist: Check Urine output (minimal 0,5-1

ml/kg/hour).
Causes of No Urine Production:
1. Kinked or disconnected foley catheter or tubing (Straighten or
connect tubing).
2. Catheter with tip obstructed by gel(Push on bladder).
3. Decreased blood pressure (Give vasoconstriction).
4. Low pump flows(Increase flows).
5. Fluid moving to interstitial space (Use Mannitol 0.5 - 1 g/kg or
lasix 0.5 - 1.5 mg/kg).

116
 Weaning From CPB and pump off
1. Preparation for weaning from cardiopulmonary bypass:
a. Re-warm to target temperatures (Temperature normal).
b. No changes in ECG.
c. Blood gas and electrolytes normal.
d. Achieve target hemoglobin.
2. Checklist before weaning from CPB:
a. Patient position on operating table is neutral.
b. vent sites, purge, and sampling line is closed.
c. Heart de-aired.
d. support prepared if necessary.
3. Surgeon: Half flow.
4. Perfusionist: Ventilating.
5. Anesthetist answer: Yes Ventilator on.
6. Perfusionist: Ok half flow (pinch the venous line by tube clamp
and slowly goes down with blood flow).
7. Mean Arterial Pressure at least 70-100.
8. CVP 5-15.
9. Surgeon: Pump off.
10. Perfusionist: Ok pump off. Stop gas flow.
11. Perfusionist: Start load the patient by blood as anesthetist order.
12. Surgeon: Remove venous cannula.
13. Scrub nurse: Open venous cannula, and placed it in front of
perfusionist.
14. Perfusionist: Drain the blood from venous cannula.
Drain the blood from venous line with permission from
surgeon.
15. Surgeon to Anesthetist: protamine please .
16. Anesthetist: Ok protamine test start protamine.
17. Perfusionist: Pump suction off.
18. Perfusionist: Continue load the patient by blood .
all blood in.
Continue flushing to prevent clotting of the aortic cannula.
19. Surgeon: Stop flushing aortic cannula out.
20. Scrub nurse: Open the aortic cannula and placed in front of
perfusionist.
21. Perfusionist: Drain the blood from aortic cannula.

117
118
111
211
 Perfusion Flow and Patient Pressure
The cardiovascular system is a complex set of vessels, within
which the blood circulates through the body, pumped by the
heart. It consists of, veins and arteries, Interposed between the
distal arterial and venous territories are the constituents of the
microcirculation, composed of arterioles, capillaries and
venules.
Selection of perfusion pressure during Cardiopulmonary
bypass is based on achieving a balance between the requirements
of surgical access (bloodless field) and patient outcome (adequate
oxygen delivery). Lower flow and pressure during Cardiopulmonary
bypass may help to improve the clearance of the surgical field,
while a higher flow and pressure contributes to reduce patient
complications.
Some patients like those who have severe atheromatous
diseases, old age, systemic hypertension, and diabetes need to
have higher perfusion pressure during Cardiopulmonary bypass.
Hypertensive patients have pressure-dependent flow patterns
develop at higher perfusion pressures than in the normal
population so they need a higher perfusion pressure during
cardiopulmonary bypass, so it is common practice in
hypertensive patients. Patients with type one diabetes mellitus
appear to have impaired metabolism-flow coupling and some
loss of pressure-flow autoregulation during cardiopulmonary
bypass.
Cerebral perfusion pressure(CPP) is the most of concern.
The brain is different from other organ systems, where the
perfusion pressure is dependent on the difference between mean
arterial pressure (MAP) and central venous pressure(CVP)
(perfusion pressure = MAP - CVP) . Cerebral perfusion pressure
is dependent on the difference between MAP and the higher
value of CVP and intracranial pressure (if intracranial
pressure(ICP) exceeds CVP, the driving force of blood across
211
the intracranial arterioles is MAP ICP and not MAP CVP).
Intracranial pressure are usually less than 5 mmHg during
CPB. Management of patients focuses on optimizing perfusion
(minimizing ICP and maximizing CPP). If cerebral venous
drainage is reduced (cannula malposition, head-down) the MAP
will not accurately reflect cerebral perfusion pressure. Treatment
of elevated intracranial pressure include , elevation of the head,
prevention of venous outflow obstruction, Mannitol at 0.5-1 g/kg
(boluses are preferred over continuous infusion as the infusion
increases uptake into brain tissue), and increase the PCO2 .
In human blood circulation the pressure gradient along the
circulation (during the systolic and diastolic), helps in
transmission of fluid between blood and tissue.
Circulatory pressure is divided into three components:
1- Blood pressure (BP).
2- Capillary hydrostatic pressure (CHP).
3- Venous pressure.
During the Cardiopulmonary Bypass, the circulation
physiology is totally modified by the introduction of a non-
pulsatile flow of the arterial side which causes increase of venous
pressure on the venous side of the circulation.
The flow control in the microcirculation is compatible to
metabolic changes for both hormonal or neural stimuli.
Cardiopulmonary Bypass is responsible for many changes in
circulation, such as increase of venous pressure, decrease of
colloid osmotic pressure, replacement of reflex and
chemoreceptors controls, and manipulation in temperature. The
replacement of the physiological controls in the capillary flow
with continuous flow instead of the intermittent flow, cause
increases in the pressure on the venous side, which forces the
microcirculation to compensate for flow deviation. In the
microcirculation, the continuous flow stimulate phenotypic cell
modification that results in the development of systemic
inflammatory response syndrome (SIRS).
212
 The flow regulation in the capillary bed occurs by the
arteriovenous communications and by capillaries sphincters,
which control the blood volume and the pressure in the capillary
bed, and can deflect the blood from the capillaries .The use of
cardiopulmonary bypass with non-pulsatile flow is detrimental
to the microcirculation, thus may cause a vascular "A-V
shunting". View Figure 7:1 .

Figure 7:1

See text in page 218 for more explanations

213
 Systemic Blood Pressure
Blood pressure: is the force per unit area exerted by the
blood against a vessel wall and is expressed in millimeters of
mercury (mmHg).
Peripheral resistance: is a friction measured between blood
and walls of vessel, it determined by: blood viscosity, blood
vessel length, and blood vessel diameter.
Blood viscosity increases as blood is more
hemoconcentrated, and decreases as blood is more diluted. In
hemodilution ,the resistance decrease and blood flows more
easily .In hemoconcentration ,the resistance increases and blood
flow will be slower. The diameter of vessels is the variable which
causes the greatest effect on resistance, the resistance drops
exponentially as the radius (half the diameter) increases. Vessel
length, if a blood vessel is longer, it will be harder for blood to
pass through that vessel, and there will be more resistance to
blood flow.
TPR: is resistance throughout the entire systemic circulation.

The pumping action of the heart generates blood flow, blood

pressure results when blood flow is opposed by resistance. The
resistance of the cardiovascular system opposes the movement of
blood, the blood pressure gradient must overcome total
peripheral resistance(TPR) to push blood through the circulatory
system and create flow. Total peripheral resistance , also known
as systemic vascular resistance (SVR) is used in calculations of
blood pressure, blood flow, and cardiac function. decrease in
blood vessel diameter (Vasoconstriction) increases systemic
vascular resistance, whereas increase in vessel diameter
(vasodilation) decreases SVR . If blood pressure increases, blood
flow increases. If peripheral resistance increases, blood flow
decreases.

214
 Systemic blood pressure is highest in the aorta, and
decreases throughout the pathway until it becomes 0 mm Hg in
the right atrium. Arterial blood pressure reflects how much the
arteries close to the heart can be stretched (compliance, or
distensibility), and the volume forced into them at a given time.
When the left ventricle contracts, blood is pushed into the
aorta, producing a peak in pressure called systolic pressure
(90-120 mm Hg).Diastolic pressure occurs when blood is
prevented from flowing back into the ventricles by the closed
aortic valve, and the aorta recoils (5090 mm Hg).
The difference between diastolic and systolic pressure is
called the pulse pressure .

The mean arterial pressure (MAP) represents the pressure

that pushed blood to the tissues .

The capillary blood pressure is low (from 4025 mm Hg)

which protects the capillaries from rupture, but is still adequate to
ensure exchange between blood and tissues. The venous blood
pressure is lower (18 mmHg in venules dropping to almost 0
mmHg at the termini of the venae cava) which changes very little
during the cardiac cycle.
Blood pressure changes with age: the arterial pressure of
infants is about 90/55, but rises steadily during childhood to an
average 120/80, and tends to increase to somewhere around
150/90 in old age. Depending on life style.

Capillary hydrostatic pressure and colloid osmotic pressure

helps to regulate the movement of fluid between capillaries and
the interstitial space.

215
 Fluid Movements in the Capillary
Hydrostatic pressure (HP): is the force of a fluid against a
membrane. Capillary hydrostatic pressure created due to the
pumping action of heart .
Colloid osmotic pressure (OP): the force opposing
hydrostatic pressure, is created by the presence of large non-
diffusible molecules that are prevented from moving through the
capillary membrane.
Fluids will leave the capillaries if net Hydrostatic pressure
(HP) exceeds net Colloid osmotic pressure (OP), but fluids will
enter the capillaries if net Colloid osmotic pressure (OP) exceeds
net Hydrostatic pressure (HP).
The difference between the capillary hydrostatic pressure and the
colloid osmotic pressure (CHP-COP = Net filtration pressure)
determines the movement of fluid between capillaries and
interstitial fluid. View Figure 7:2 .

216
 Basic Principles of Perfusion Flow
Blood flow: is the volume of blood that is ejected through
the circulatory system in a specific period, it may be expressed as
L/min. This process ensures the transportation of nutrients,
hormones, metabolic wastes, gases. Blood flow is equal to
cardiac output.
Cardiac Output (CO): The total output of the heart over
time.
Normal Perfusion (CPB) Flow: it is the amount of blood
that must be pumped at most of cardiopulmonary bypass time, at
normal temperature (37 C), to deliver the tissues needs of
oxygen and food. See Table 32.
Maximum Perfusion (CPB) Flow: is the largest amount of
blood can be pumped if that necessary, for any reason such as
pressure drop or physiopathological particularities ,regardless of
the patient's temperature ,which based on patient age\weight,
size of aortic cannula ,and size of oxygenator. See Table 32.
Table 32 : Blood Flow Rate Using the BSA
Pediatric Normal Flow Maximum Suggested
Patient Age Flow
Flow = CI X BSA Flow = CI X BSA
Newborns - 2y. 3.2 - 3 x BSA 4 x BSA
24y 2.8 x BSA 3.8 x BSA
46y 2.6 x BSA 3.6 x BSA
6 10 y 2.5 x BSA 3.4 x BSA

Adult Normal Flow Maximum Suggested

Patient Weight Flow
Flow = CI X BSA Flow = CI X BSA
> 80 Kg 2.4 x BSA 3.2 x BSA
80-100 Kg 2.4 x BSA 3.0 x BSA
<100 Kg 2.4 x BSA 2.8 x BSA

217
nnMinimum Perfusion (CPB) Flow: is a lowest sufficient amount of
blood that can be pumped to patient , at reduced of temperature, to reduce the
amount of back flow and provide a bloodless field when the surgeon need it to
work,or to reduce the pump side effects on blood in complex and long cases .
See Table 33

Table 33: Minimum Blood Flow Depending of Patient Temperature

Hypothermia (C) Temperature Flow index
Mild hypothermia 3734 C 2.4 l/min/m2
Mild hypothermia 3432 C 2.2 l/min/m2
Moderate hypothermia 3230 C 2.0 l/min/m2
Moderate hypothermia 28 C 1.8 l/min/m2
Deep hypothermia 26 C 1.6 l/min/m2
Deep hypothermia 24 C 1.4 l/min/m2
Deep hypothermia 22 C 1.2 l/min/m2
Deep hypothermia 20 C 1.0 l/min/m2
Deep hypothermia 18 C 0.8 l/min/m2
Profound hypothermi 16 C 0.6 l/min/m2

There is a strong relationship between the value of patient

pressure and the amount of perfusion flow. The sufficient amount
of perfusion flow without good value of pressure that mean lack
of blood supply to the small tissues. Furthermore, the appropriate
value of pressure without sufficient amount of perfusion flow
(suitable for the patient's temperature) will be not enough to give
the tissues needs of oxygen.
So, if you go to a maximum amount of perfusion flow for the
patient, without gaining the adequate pressure, you must use the
medications to raise the patient pressure to ensure the blood
supply to the small capillaries is good. Furthermore, if you need
to reduce the flow rate (suitable with the patient's temperature),
but the patient pressure is low, you must raise the patient
pressure first by the medications, and then you can reduce the
perfusion flow rate to a level consistent with the patient's
temperature.
218
 Conduct of Perfusion Pressure
The perfusionist work to maintain the required perfusion
pressure. To achieve these perfusion pressure goals the team
(perfusionist and anesthetist) have two general choices:
modifications of pump flow or administration of vasoactive
medications . In the case of hypotension, the pump flow may be
increased, if surgical conditions allow it. Alternatively,
phenylephrine and noradrenaline may be used to support
perfusion pressure . In the case of hypertension, the pump flow
may be reduced, although this reduction of the blood flow may
increases the possibility of inadequate oxygen delivery if the
flow rate is not appropriate for the patient's temperature ;for more
safety, a vasodilator( sodium nitroprusside or nitroglycerin) can
be administered.
The beginning of cardiopulmonary bypass is often
associated with acute transient state of systemic arterial
hypotension, due to the dramatic decreases in viscosity
that result from dilution, and activation of systemic
inflammatory response. Also, the decreased in oxygen
delivery that occurs in the early period of hemodilution
at initiating CPB, cause to acute release of vasodilation
substance, which resulting peripheral vasodilation. After
the initial decrease, systemic arterial pressure often begins to
increase spontaneously, maybe by reflecting activation of the
renin-angiotensin system or sympathetic nervous system. If
the pressure doesn't rise to normal levels after a few minutes
, it may necessary to add vasopressor agents, to increase
perfusion pressures for maintenance of cerebral blood flow.
The correct blood pressure during bypass is imperative.
Lower pressures may reduce cerebral blood flow .Higher
pressures (higher than 100 mmHg) can lead to impairment of
tissue perfusion as well as the risk of intracranial hemorrhage.
211
Pressures less than 50 mmHg are avoided if possible in adults.
Pressures higher than 60 mmHg are used during rewarming.
Pressures up to 70 - 90 mmHg may be used in patients with
cerebral vascular disease.

Hypertension is often treated by decreasing systemic

vascular resistance with volatile agents or the continuous
intravenous administration of nitroprusside. Nitroglycerin has
reduced the systemic vascular resistance because of its action in
vasodilatation . At low doses, nitroglycerin will dilate veins more
than arteries, thereby reducing preload. But at higher doses, it
also dilates arteries, thereby reducing afterload.

Increased central venous pressure and inadequate venous

return may reflect incorrect position of the venous cannula which
leads to obstruction of venous drainage. For example, placement
of a cannula too far into the superior vena cava can obstruct the
right innominate vein, leading to an increase of cerebral venous
pressure and cerebral edema. Insertion of a cannula too far into
the inferior vena cava can obstruct the hepatic vein, resulting in
abdominal distention.

To assess perfusion flow, blood gases and pH are monitored

frequently during cardiopulmonary bypass. A mixed venous PO2
lower than 30 mmHg is associated with metabolic acidosis ,that
refers to inadequate tissue perfusion. Urine output is a guide to
the adequacy of renal perfusion(Minimally 0,5-1 mL/kg/hour ).
During total cardiopulmonary bypass, the ventilator is
stopped and the lungs are left quiescent. However, at partial
cardiopulmonary bypass , when the systemic arterial pressure is
pulsatile and the pump not full flow, the lungs should be
ventilated ,to oxygenate the blood which is ejected from the
heart.

211
 Pulsatile Flow
Many investigations of the significance of the pulsatile blood
flow during CPB were carried out, and demonstrated that
pulsatile flow generates more hemodynamic energy, which
maintains better microcirculation compared with non-pulsatile
flow. The difference of pressure (that caused by the pulsatile
flow) between the two ends of the vessel is important, because
the blood flows from high to low pressure. The pulsatile flow
delivered energy to the circulation up to 3-4 times more than
non-pulsatile flow, this energy might be responsible for
maintaining normal peripheral blood flow distribution.
Non-pulsatile flow perfusion lead to progressive systemic
arterial vasoconstriction, this vasoconstriction eventually lead to
reduced visceral perfusion, increased afterload, and decreased
cardiac output at separation from CPB. Many studies showed that
the use of pulsatile perfusion during CPB associated with a
reduction in the vasoconstriction compared to the non-pulsatile
flow.
The most useful effect of the use of pulsatile flow may occur
in the region of the microcirculation, this useful effect was the
result of improved gas exchange at the capillary level, where the
energy (Hydrostatic energy) of the pulsatile flow accrues in the
form of blood flow and intravascular pressure, resulting in
facilitating the interstitial diffusion and maintaining of the
arterioles patency (Keep it open, which may be collapsed(A-V
shunting occurs) during the non-pulsatile flow). In addition, the
continued opening of arterioles reduces the stress produced by
211
the decreased release of endothelial vasodilators. Furthermore,
many researchers have shown that the pulsatile flow improves
cerebral blood flow and might be responsible for preserving renal
function from tubular changes, which happens during the use of
non-pulsatile flow.
Pulsatile flow is a complex issue that remains the focus of
many studies, and it is generally believed that that the pulsatile
flow is beneficial or even necessary to maintain the body's
physiological state, and reduce complications that associated
with the use of CPB.

212
 Significance of The Pulsatile Flow
1. Improved blood flow of the vital organs including brain,
heart, liver, kidney.
2. Reduced the systemic inflammatory response syndrome,
and decreased the incidence of postoperative deaths in
pediatric and adult patient.
3. Reductionin the vasoconstriction and systemic vascular
resistance during CPB and increase cardiac index
immediately following CPB, due to the decrease in
afterload (reduction in post-CPB vascular resistance).

4. Prevents occurrence of capillaries arterial-venous shunting.

5. Pulsatile flow has been associated with a higher rate of
oxygen consumption and a reduction in the level of
metabolic acidosis. The difference of pressure that caused
by the pulsatile flow increases the effectiveness of the
gases exchange ,and fluid transmission in microcirculation.
6. Reduce need for pharmacologic interventions and IABP
used post CPB period.

Warning: During use of pulsatile flow, line filters (screen filter) must
be used to remove gas emboli, which may be formed in
the membrane blood phase due to sudden decrease and
increase in flow. If the pressure gradient is even
momentarily, positive in favor of the gas phase.
Warning: Do not used the pulsatile flow if the aorta is calcified.

Note: If the pulsatile flow used ,the aortic cannula must be inserted in
the ascending aorta, and it should be of adequate size to
transmit the pressure wave ,to achieve the desired goals of the
pulsatile flow .

213
 Pulsatile Flow Perfusion Pumps
The type of artificial pumps is the responsible for providing
a satisfactory pulsatile flow that can mimic the characteristics of
pressure output of the human heart.

1-Roller Pump.
These are the most widely used type of pump. These pumps
consist of rollers (usually two) positioned on the end of a rotating
arm. Forward flow is induced by the rollers compressing tubing
mounted at all times in a U-shaped raceway. The flow rate is
dependent on the diameter of the tubing, the diameter of the
raceway and the rotation rate of the rollers.
This pump be capable of generating some degree of pulsatile
blood flow. The stepping motor , permit to the pump head to
rapid acceleration and deceleration production of the pulse cycle.
While using the pump control module to adjust the baseline flow
rate ,output frequency, and pulse duration, in addition to total
flow rate ,to adjust the pressure curve .
The most fear among users was that the rapid acceleration
and deceleration of the pump head during pulsatile flow might
cause increase in hemolysis due to the increase in shear rate that
occurs under pulsatile blood flow conditions, but the vitro and
vivo studies denied that.

Otherwise, the roller pump generated pulse pressures at

range of 10-30 mmHg , but the output pressure curve of roller
pump is less than optimal, it is not capable of matching the
hydraulic power output of the human heart, the pressure curve
shown during cardiopulmonary bypass (without any cardiac
activity) is not similar to the usual physiological blood pressure
curve. However, there is clear evidence that there a clinical
benefits are resulting from its use.

214
2-Ventricular Blood Pump.
The ventricular pumps are the most physiologic method for
generating pulsatile blood flow, they operate in a similar
technique to the ventricle of the heart.
Ventricle pumps are consist of a compressible sac (chamber)
mounted in a rigid casing and two one-way valves permitting
blood to flow into and out of the chamber in only one direction.
Mode of Action and Mechanism of Ventricular Pumping:
The ventricle is typically driven by either liquid(e.g. water)
or gas. The liquid or gas, fills a sac within the blood chamber,
causing increased pressure in blood chamber, result to displace
the blood within the blood chamber through the outlet valve.
Then the liquid or gas is vented from the sac, thereby decreased
pressure in blood chamber, blood chamber returns to its original
shape ,and refills with blood through the inlet valve. View Figure 7:3.

Figure 7:3 : The blood flow is directed by one-way inlet and outlet valves.
(A). Fill cycle: the water is vented from the sac ,and blood chamber fills with blood
through the inlet valve .
(B). Ejection cycle: the water is filled the sac to displacement blood in the blood
chamber through the outlet valve.

215
 The output of the ventricle pump depends on the rate of
pumping action, the chamber size, the resiliency of the sac ,and
the characteristics of the valves(at which pressure it operates).

The advantages of ventricle pumps ,the little blood trauma,

and reliability of positive displacement flow (as normal heart
flow.

The disadvantages expensive because including valve ,

mechanical complexity, limitations in the range of output ..
Ventricle pumps have been employed in clinical practice
with some success. However, widespread use of ventricle pumps
has been impeded, due to their considerable cost in terms of both
mechanical and disposable components.

3-Compression Plate Pump .

Compression plate pump consist of an elastic tube between
two metal plate boards, and two one-way valves permitting blood
to flow in only one direction . The elastic tube is based at the
rigid back plate and compressed via a moving plate.

Mode of Action And Mechanism of Compression plate pump:

In ejection cycle the resilient tube (contained the blood) are
compressed by the moving plate, causing increased pressure in
tube, resulting in ejection of a volume of perfusate from the tube
through the outlet valve . In refill cycle, the moving plate come
back and the resilient tube returns to its original
shape(expansion) , causing decreased pressure in tube ,and refill
it's with blood through the inlet valve. View Figure 7:4 .

216
 Compression plate pumps have a significant control of pulse
wave. The pulse rise time can be controlled by the rate of
compression of the tube, and the flow rate by changing the
frequency or the length of compression of the compression plate.

The internal valves employed in compression plate pumping

systems has prevented their widespread use. The considerable
cost of the internal valves has led to many promising systems
being shelved before clinical use.

Arterial-venous Shunting
Arteriovenous shunts: is the flow of the blood direct
from arteries to veins ,with bypassing the capillaries.
View Figure 7:5 .

217
 Arterial-venous Shunting
Arteriovenous shunts: is the flow of the blood direct from
arteries to veins ,with bypassing the capillaries. View Figure 7:5.

Generally, all the blood pass from arteries to capillaries and

thence to veins. In many tissues, there are direct pathways
between the arteries and veins that allow blood to bypass
capillaries. These pathways are called arteriovenous shunts. This
shunting is normal in certain conditions when it is necessary to
use the oxygenated blood in other areas. But, the A-V shunting
may occur inappropriately during CPB and causes tissue
hypoxia.

218
 When the A-V shunting occur the oxygenated blood is not
distributed to the tissues, but it is moves across a bridge that
bypasses the capillaries to the venous side, thus causes tissue
hypoxia (gas exchange between blood and tissue not happened).
A-V shunting will cause certain unusual blood gas values(High
Venous Po2, and decrease A-V Po2 Difference).

Causes of Shunting during CPB:

1. Stress of surgery.
2. cooling.
3. certain medications.

Signs of Shunting:
1. High Venous Po2.
2. 2.Low Systemic Arterial Blood Pressure.
3. Decreased A-V Po2 Difference .

Correct of Shunting:
1. Substitute the continuous flow with pulsatile flow.
2. Rewarming the patient.
3. Giving vasodilation medications.

211
221
221
Pediatric Cardiopulmonary bypass Techniques
The use of cardiopulmonary bypass in children with
congenital cardiac diseases involves an important differences
compared with its use in adults with normally connected hearts.
Furthermore ,the procedures in neonates and infants are likely to
involve much greater differences from adults procedures.
The perfusionist who is specialized in pediatric has a lot of
challenges compared with the perfusionist who is specialized in
adult ; due to the great variety of pediatric surgical interventions,
and the significant difference in weight from patient to another .
Therefore, the specialized pediatric perfusionist should have the
advanced knowledge of all the various surgical interventions and
consequent differences of cardiopulmonary bypass procedures,
the various types oxygenators and their different sizes, the
appropriate size of the circuit for each patient, characteristics and
numbers of cannulas for different procedures, the appropriate
temperature values for each case and the amount of flow
sufficient for each temperature.
This chapter outlines the general considerations for pediatric
perfusionist, including many of the policies, techniques, and
strategies that is used in the application of cardiopulmonary
bypass, including differences between pediatric and adults,
acceptable hemodilution, vacuum assisted venous drainage
(VAVD), deep hypothermic circulatory arrest (DHCA), and
cerebral blood flow, and modified ultrafiltration(MUF).
In this chapter there are techniques or procedures that are
used commonly in both children and adults. But I have included
all these techniques in this chapter because it's been widely used
in children, or because the associated effects for use of these
procedures and techniques will be much greater in children than
in adults.
222
 Differences Between Pediatric and Adults
Differences in Tube Circuits Size
The circuit size of cardiopulmonary bypass must be able to
provide appropriate full flow bypass, avoiding the over
hemodilution . For children less than three kilogram , a circuit
can be accomplished by employment of 1/8 inch tubing for the
arterial line ,3/16 inch in the venous line,and1/8 inch for the
suction and sump(vent). The use of a small diameter tubing for
suction and sump help to decreases the steal of blood from the
total circulating volume when actively filled. Low prime arterial
line filter( such as Dideco KIDS D130 from Sorin Group with a
priming volume of 16 ml) must be used, to perform a bloodless
priming. Otherwise, if you dont have a low prime arterial line
filter, you can skip the use of a large ordinary arterial filter which
does need a large priming volume by excluding the use of arterial
filter. Even though the necessity of arterial filtration for neonates
is debatable, the circuits without arterial filter have been
successfully used in many cardiac centers without any significant
complications.
The following table shows the sizes of the circuit that can be used
(depending on the patient's weight) to reduce the possibility of blood
transfusion in priming.

Table 6: Arterial and Venous Line Size as patients weight

Patients weight Arterial Line Size Venous Line Size
> 3 Kg 1/8 Inch 3/16 Inch
3-6 Kg 3/16 Inch 3/16 Inch
6-9 Kg 3/16 Inch Inch

9-20 Kg Inch Inch

20-35 Kg Inch Inch

35-50 Kg Inch Inch

Above 50 Kg Inch Inch

223
 Differences in Cannulation
In general ,the cannulas must be flexible and durable to
maintain their shape and flow characteristics despite of the
manipulation in temperature and pressure during hypothermic
CPB. In neonates and infants, the use of miniature cannulas
presents a significant technical challenge for perfusionist.
Arterial cannulation: The tip of aortic cannula must be
small in neonates and infants (because they have a tiny aorta), to
simplify insertion and to prevent impedance of native normal
aortic blood flow around the cannula (before initiation of CPB
and after weaning from CPB) to maintaining cardiac flow.
Otherwise, the cannula must be adequate for perfusion flow rates.
Excessive pressure in the cannula tip may create a powerful jet of
blood, which can damage the intima of the aorta and blood
cellular elements. The use of straight tip arterial cannula allows
employing small tip size cannulas without excessive pressure.
In general, the arterial cannula placed into the ascending
aorta. In some pediatric cases, the type of surgical procedure
and the anatomy of great vessel may lead to change the
cannula placement. For example:
In hypoplastic left heart syndrome, the ascending aorta is too
small to receive the arterial cannula. Therefore, the arterial
cannula is placed in the main pulmonary artery, systemic
perfusion flows from the pulmonary artery through the ductus
arteriosus (to prevent excessive perfusion of the pulmonary
vascular bed, the right and left pulmonary arteries are occluded
with snares).
In neonates with transposition of the great arteries, the
arterial cannula is placed more distally in ascending aorta
because a large portion of procedure is performed on the aortic
root.
In some interrupted aortic arch cases, two aortic cannulas are
used, the first one in the ascending aorta to perfuse the head and
neck vessels and the second in the descending aorta to perfuse
the body.
224
Venous cannulation: Venous cannulation can be very
complex in patients with congenital cardiac defects, due to many
anomalies in cardinal veins (IVC and SVC), such as bilateral
superior venae cava(Left SVC), azygos continuation of the
inferior vena cava (IVC), double IVC, or hepatic veins drain
directly into an atrial chamber. If one of these anomalies is
present, venous cannulation of these anomalies must be included.
In the repair of defects associated with anomalies of systemic
venous return, three venous cannulas might be required.
Appropriate placement of venous cannulas is necessary to
achieve effective systemic perfusion. A poorly positioned venous
cannula may cause vena cava obstruction. If SVC obstruction
occurs, it will cause elevation in jugular venous pressure,
cerebral edema , and decrease cerebral perfusion pressure .If the
obstruction occurs in IVC, this may cause decreased venous
return from the splanchnic (renal, and hepatic) and abdominal
(mostly liver) congestion, and reduce perfusion pressure across
the mesenteric ,renal, and hepatic. Observation the SVC
pressures via an internal jugular line or looking at the patient's
head for signs of venous distension after initiation of bypass may
be the ways to detect systemic venous congestion. The
perfusionist should discuss the adequacy of venous return with
the surgeon if potential venous cannula problems occur.
The venous cannulation can be simplified, by the use of
deep hypothermic circulatory arrest procedure. The repair occurs
during the arrest period, a large single venous cannula is placed
in the right atrium to achieve effective venous drainage. After
cooling the patient to arrest temperature the cannulas are
removed and surgery proceeds in a cannula-free field.
The amount of venous return is depending on cannula size,
patient anatomy, site of insertion, and adequacy of cannula
position. The use of short angled venous cannulas is more
effective in venous drainage and less obstruction of the surgical
field. A short cannula avoids placing the cannula tip beyond the
hepatic veins which causing hepatic venous obstruction.
Recently, a system of assisted venous drainage has been
developed in which negative pressure is applied to the venous
reservoir and blood is actively evacuated from the atria. This may
225
allow for decreased priming volumes and reduced sizes of
venous cannulas. See Table 34 .
Table 34: Venous Cannula Size With Assisted Venous Drainage
Two Cannula Single Cannula
Patient Angled Tip Cannula Straight Tip Cannula
Weight
SVC IVC RA two-stage
1-3 10 12 14
3-4 12 12 16
4-5 12 12 18
5-6 12 14 18
6-8 14 16 20
8-10 16 16 20
10-12 16 18 22
12-15 18 18 22
15-20 18 18 24
20-25 18 20 24 24/32
25-30 20 20 26 24/32
30-35 20 22 26 29/29
35-40 22 22 28 29/29
40-45 22 24 30 28/36
50-60 24 24 32 32/40
60-70 24 26 34 32/40
70-80 26 26 36 32/40
< 90 26 28 36 34/46
Note: The venous cannula type and style has direct impact on flow rates.
When the vacuum assisted venous drainage is used, smaller certain
cannulas are used with large holes (e.g. DLP Right Angle Metal
Tip) or cannulas with multiple side holes to minimize occlusion, if
ordinary cannulas are used it might be difficult to achieve effective
venous drainage.

226
 Major Differences Between Adult and Pediatric CPB
The following table shows some of the differences between
adult and pediatric in policies, procedures and strategies that
employed in cardiopulmonary bypass.
Table 35: Differences Between Adult and Pediatric CPB

Parameter Adult patient Pediatric patient

Male 70 ml/kg >10 Kg 85 ml/kg

Estimated blood
volume 10-20 Kg 80ml/kg
female 60 ml/kg 21-45 kg 75 ml/kg
Dilution effects on
25 - 33% 50 - 200%
blood volume
Oxygen consumption 2 3 ml/kg/min 6 8 ml/kg/min

<3 Kg 150-200

ml/kg/min
3-7 Kg 120-190
Full CPB flow at 50 75 ml/kg/min 7-10 Kg 100-170
37C 10-30Kg 80-120
30-50Kg 75-100
Minimum CPB
Commonly 32 - 37C Commonly 18 - 28C
temperature
Temperatures
gradient
10-12C 8C
(between blood and
water)

Perfusion pressures 50 90 mmHg 20 70 mmHg

Acid-base Mainly Alpha-stat Alpha-stat and/or pH-stat

management
Measured PaCO2
35 45 mmHg 20 60 mmHg
differences

227
 Acceptable hemodilution During CPB
Hemodilution is used during CPB to reduce the viscosity of
blood during hypothermia and to reduce the need for blood
transfusion. The small amount of blood volume in infants and
neonates with comparison to the extracorporeal circuit volume
can complicate several aspects of the conduct of cardiopulmonary
bypass. In adults, the extracorporeal circulation priming volume
is only about 2533% of the patients blood volume, while the
extracorporeal circulation priming volume in neonates may
exceed the patients blood volume. The most common pediatric
pump circuits have a total volume between 300 and 800 mL
which might be about 100200% of the patients blood volume.
This leads to significant hemodilution at the beginning of
cardiopulmonary bypass, or the need to add blood to the circuit to
avoid the extreme hemodilution after initiation of cardiopulmonary
bypass.
Extreme hemodilution results in a reduced concentration of
plasma proteins and all coagulation factors as well as active
platelets which contributes to the risk of interstitial edema and
coagulopathy, this might increase the risk of bleeding (which is
potentially high because the cardiopulmonary bypass activates
the fibrinolytic system) . Extreme hemodilution also might cause
electrolyte imbalances, which might result in a release of stress
hormone, and eventually might activate the inflammatory
pathways.
The optimal hematocrit for humans during cardiopulmonary
bypass is still a contentious issue. Some study suggests that an
optimum hematocrit is 22-30 %. But other studies showed that
the hematocrit of 35% on-bypass is a reasonable goal. The
acceptable levels for hemodilution on deep hypothermia are not
specified, but generally a hematocrit between 21 and 28% is
used for deep hypothermic arrest.
228
 During CPB, hemodilution reduces viscosity. As viscosity is
reduced the peripheral resistance is reduced and the regional
blood flow increases. But the use of hypothermia during
cardiopulmonary bypass causes a rise in blood viscosity and
reduced tissue perfusion, so it appears prudent to avoid the high
hematocrit during deep hypothermia. The degree of hemodilution
during hypothermic cardiopulmonary bypass is based on the
degree of hypothermia.
This relationship led as suggested by some studies- to
employ a lower hematocrit when the greater degree of
hypothermia is used. Hematocrit less than 21% can be
tolerated in cases of circulatory arrest, or in patients who will
not accept blood transfusion (Jehovah's Witnesses patients) . The
observations confirmed that the patients are able to tolerate the
reduced in hematocrit even very low levels (15%) during deep
hypothermic cardiopulmonary bypass without obvious
neurological or other consequences.
Another consideration in allowable hemodilution is an
acceptable hematocrit at initial stages of bypass, in the early
phase of bypass the brain is still warm and has a normal high
metabolic rate. Thus although the chosen hematocrit level may be
acceptable for the target temperature, nevertheless injury may
occur in the early phase of cooling when the metabolic rate is still
high and oxygen delivery is limited due to the reduction in
hematocrit (which cause of decreased oxygen-carrying capacity
of the blood), so it would seem prudent to start the bypass at
hematocrits above this level.

Advantages of hemodilution
The reduced need for blood transfusion is the most obvious
advantage of hemodilution for patients undergoing
cardiopulmonary bypass.
Hemodilution with the use of clear priming fluids
(comparison with blood prime) has reduced post-operative
221
 renal failure, pulmonary insufficiency, thrombo-embolic
events.
Hemodilution is associated with a reduction of blood
viscosity and increased tissue perfusion. As a consequence,
pressure value less than the natural values of the pressure is a
sufficient to maintain adequate tissue perfusion during CBP
(20-70 mmHg in pediatric and 50-90 mmHg in adult),
with a notable absence of metabolic acidosis, as a result of
reduced systemic vascular resistance.

Disadvantages of hemodilution
Hemodilution contributes to the capillary leak which is
associated with cardiopulmonary bypass.
But the use of appropriate colloid, such as human albumin
solution, fresh frozen plasma, and starches (HES) is helpful
to counteract this.

Hemodilution and Oxygen Carrying Capacity

The hemoglobin in red cells allows for efficient transport of
oxygen from the lungs to the cells .The hemoglobin is carrying
about 97% of oxygen , it transport of very much greater
volumes of oxygen than could be dissolved in plasma (3%) .
During cardiopulmonary bypass , the dilution from a normal
hematocrit of 40% to a hematocrit of 30% is frequently used, this
results in a 25% reduction in total oxygen content (decreased
oxygen-carrying capacity of the blood). However ,the
combination of reduction of metabolic rate due to anesthesia
(including the muscle relaxation), increase the value of Po2 to
150-200 mmHg during CBP, and used the hypothermia is more
than adequate to compensate this reduced in oxygen carrying
capacity.

231
 Oxyhemoglobin Dissociation Curve
mmmmEach shifts in the oxyhemoglobin dissociation curve can
significantly affect in hemoglobins ability to pick up or delivery
oxygen at the tissue level. In a more acidotic environment, the
oxyhemoglobin dissociation curve is shifted rightward so that
oxygen is more freely released. In a more alkaline environment
the oxyhemoglobin curve is shifted to the left so that oxygen
remains more firmly attached to hemoglobin. See Table 36.

Table 36: The Oxyhemoglobin Dissociation curve

The Curve Shift To The The Curve Shift To The
Reasons Of Curve Shift

Right Left
(oxygen is more freely released (oxygen more attached to
From hemoglobin) hemoglobin)
Metabolic Acidosis Metabolic Alkalosis
Hypercarbia (Increased Hypocarbia (Decreased
PCO2) PCO2)
Hyperthermia Hypothermia
Increased 2,3-Diphosphoglycerate Decreased 2,3-Diphosphoglycerate
(2,3-DPG). (2,3-DPG)
2,3-Diphosphoglycerate (2,3-DPG): is a three-carbon isomer acid
made in the red blood cells. It controls the movement of oxygen from red
blood cells to body tissues.

231
 Hemodilution Level Management
To achieve the target hematocrit on CPB, small circuits,
prime replacement, PRBC transfusions, pre-pump phlebotomy
and hemoconcentration can be utilized.
The level of hemodilution at the initiation of bypass is
determined by:
1- Decrease the amount of the priming volume: Try to use a
small circuits to minimize the priming volume required to
reduce the need for transfusion.
2- Addition blood to the prime solution( In case of low PCV
per bypass): After determination of the target hematocrit the
blood is added to the prime according to the following
formula.

TBV : Transfused Blood Volume ( ml).

HT2 : Target Hematocrit During Pump.
HT1 : Preoperative Hematocrit .
CV : Circulating Volume Of Patient .
CPBV : Priming Volume In The CBP Circuit .
HT TBV : Hematocrit Of Transfused Blood ( 40 % ).

If the result is positive needs a blood transfusion. If the

result is negative needs per bypass blood separation.
3- Pre-pump phlebotomy (Intraoperative autologous blood
donation):
If the patient have a high PCV we can separate amount of
patient blood via venous line in the immediate pre-bypass
period: To calculate the amount of blood that must be
separated used the previous formula (negative result).

232
4- Pre-cardiopulmonary bypass prime replacement
(autologous priming techniques) "depriming":
As an attempt to not use the blood in prime, pre-CPB
prime replacement can be accomplished if the patient have a
good blood volume with low PCV.
Pre-CPB Prime Replacement Technique"depriming":
Before beginning of CPB, remove any extra volume
from reservoir .
After cannulation, through a Y-connector (which placed
at the arterial-venous shunt and connected with transfer
bag) drain the patient via the venous line into a transfer
bag to remove the priming from the venous line
(antegrade venous priming).
Drain the patient via the arterial line into a transfer bag
to remove the priming from the arterial line (retrograde
arterial priming).
In addition ,if the patient blood volume is still allows, all
of the priming volume in membrane and arterial filter
may be replaced with patient blood ,by draining more
blood volume from venous line to reservoir ,and running
the arterial head , while the arterial line clamped to push
the priming to the transfer bag.
Note: It is appropriate to use alpha agents by anesthetist such as phenylephrine
immediately before bypass to augmented the blood pressure to aid the perfusionist to
accomplish the autologous priming strategies safely.

Optimal Hematocrit after Bypass

The acceptable hematocrit after bypass varies from case to
case and depends on the diagnosis, degree of functional
impairment, and planned surgical procedure (e.g. postoperative
mixed circulation patients require a normal hematocrit at the
separation from bypass). In general, it would seem prudent to
increase the hematocrit to approximately 30% before the
termination from bypas
234
 Vacuum Assisted Venous Drainage Technique
Vacuum assisted venous drainage is a technique that utilizes
a vacuum or source of negative pressure to create a negative
pressure in the venous reservoir, to apply active venous drainage
(closed system of venous return) instead of gravity drainage,
consequently eliminating the principles of trapping and gravity.
The amount of vacuum applied generally is between
- 20 to - 80 mmHg of negative pressure. To adjust the vacuum
pressure needed, use a vacuum regulator. A vacuum regulator are
provided in a vacuum line between the wall (central) vacuum and
the reservoir to regulate the negative pressure. The central source
supplies negative pressure of approximately 170 mmHg, the
regulator steps the negative pressure down to between 0 and 80
mmHg within the reservoir. At beginning of bypass, turn on the
vacuum regulator at 20 mmHg, and increase the blood flow
rate until adequate perfusion .It is recommended to use the
minimum vacuum assist necessary for adequate perfusion
.Assess the necessary increase the vacuum (don't exceed -80) in
order to increase the level of the venous return.
A relief valve and vacuum stabilizing valve may be included
in the system for safety. The vacuum stabilizer valve work to
protect against excessive negative pressure, when the negative
pressure increases within the system to a predetermined threshold
value, the vacuum stabilizing valve bleeds air into the system to
prevent the large increase in negative pressure .The relief valve
provide the function of pressure relief, if pressure within the
reservoir buildup to positive pressure, the relief valve cracks
open to bleeds air out of the line .
For more safety, a Y-connector(vacuum relief controls)
should be placed between the regulator and the reservoir, with
PVC tube extending from the Y-connector. The PVC tube is
clamped during operation by using surgical tubing clamp to
apply the closed condition (negative pressure). However, release
235
of the clamped opens the system to atmosphere to enable a quick
disconnect of the negative pressure if the suction increases too
rapidly, or other conditions require termination of the vacuum.
Causes of used Assisted Venous Drainage
In Adults
1- Video-assisted surgical procedures and minimally invasive
techniques with CPB.
2- Optimize venous return flow with the utilization of a
reduced diameter venous cannulae.
In Pediatrics
1- Reduce priming volume (smaller diameter lines).
2- Excellent handling for air locks in the venous line.
3- The use of smaller diameter venous cannulae allows to
reduce the clutter in the operative field (which is relatively
small due to a small incision), and offers a large area of the
surgical work.
Advantages of VAVD
1- Improved venous return during CPB.
2- Reduction in venous cannula size ,and miniaturization of
the entire CPB circuit.
3- Reduced the priming volume for extracorporeal circuit and
reduce of hemodilution.
4- Reduced dependency of blood products, especially in
pediatric patients.
5- Markedly reduced intra-cardiac suction levels.
6- Improved visibility and ability to use smaller incisions for
surgical repair.
7- A miniaturization of the CPB circuit would lead to
minimizing blood contact with foreign surfaces thereby
reducing complications associated with immune response
8- Almost impossible to have an air-lock in the venous line.
9- Improved drainage in special procedures (e.g. femoral vein
cannulation).
236
Assisted Venous Return Techniques:
1- Roller- Pump Assisted Venous Drainage (RAVD)
Includes integration of a roller pump in the venous line to
actively aspirate venous blood from the patient. View Figure 8:1.

2- Kinetic-Assisted Venous Drainage (KAVD)

Includes integration of a centrifugal pump into the venous
line to actively aspirate venous blood from the patient. View Fig. 8:2.

237
 3- Vacuum-Assisted Venous Drainage (VAVD)
The vacuum assisted venous drainage (VAVD) is the most
recent technique of assisted venous return , it aiming to optimize
the venous drainage, and reduce the use of crystalloids in order to
obtain higher values of hematocrit .
With this technique, the venous line is connected directly the
venous reservoir, a vacuum regulator is connected to the
reservoir and all vented ports are closed. View Figure 8:3 .

With vacuum assisted venous drainage , the venous return

flow rates will no longer depend on the physical location of the
reservoir with respect to the operating table, this allows to
placement the oxygenator higher , and shortening the CPB circuit
lines , leading to a reduction of hemodilution related to the low
priming volume of crystalloid which added to completing the
circuit, compared with operated with gravity venous drainage.
VAVD is not substitution for good cannulation. During a
cardiopulmonary bypass the rate of venous blood flow through
the system which is monitored, and not the venous blood
pressure levels, since the goal of the CPB system is to reduce the
pressure as low as possible, while continuing to maintain
adequate blood flow to and from the patient via the system.
238
 Vacuum Assisted Venous Drainage Management
Negative pressure in the venous reservoir should be
monitored continuously and adjusted appropriately for efficient
venous return augmentation. Do not allow the negative
pressure in the venous reservoir to exceed greater than 80
mmHg. Whenever the blood flow rate is lowered intermittently,
reduce or turn off the vacuum. If venous return stops during
CPB, clamp the venous line for a second and release. When
blood volume is transferred to the patient(half flow) to initiate
weaning from CPB, terminate vacuum assisted venous drainage.
Warning: Do not connect the VAVD to any other ports than the reservoir vent port.
Otherwise the negative pressurized circuit may suck blood in it.
Warning: Do not use regulator with maximum pressure greater than -150 mmHg. Use
excessive negative pressure may lead to hemolysis.
Warning: All A\V shunt lines(sampling line, purge line,) must be closed when the pump
stopping or using low flow rates to prevent drawing air into the blood side of
oxygenator from fiber due to drawn pressure in blood side of membrane.
Warning: If circulatory arrest is required, vacuum is removed from the reservoir and
only applied again when restarting bypass.
Warning: If VAVD used, a positive\negative pressure relief valve should be used.
Over pressurization of venous reservoir could obstruct venous drainage.
Warning: Do not open any auxiliary port on venous reservoir during VAVD.
Warning: Proceed slowly when returning to atmospheric pressure (elimination of
vacuum) .A sudden change may create turbulence of the blood inside the
reservoir.
Warning: If VAVD used, the line between the oxygenator and centrifugal pump must be
clamped before stopping pump. Otherwise an air may draw into blood side from
the fiber.

Disadvantages of VAVD
Possibility of transmission of micro-emboli to the arterial
side of the circuit.
Excessive negative pressure may lead to hemolysis.
It may distort the inter-atrial septum due to negative
pressure in the RA.
It may cause displacement of retrograde cardioplegia
cannula.

231
 Avoiding Blood Transfusion
for pediatric on CPB
Over recent years increasing awareness has been sparked to
the risks of using donor blood products, and became a trend
towards reducing blood transfusions, as often as possible.
There is many risks associated with the use of donor
blood(complement activation, viral particle transmission,
transfusion reaction, high lactate, high potassium).

Structural and functional changes that get in packed red

blood cells due to storage:
1- Hyperkalemia (Storage time 2 Days K+ 5.7 6.7 mmol/l .
Storage time 28 Days K+ 31 38.5 mmol/l ).
2- Increased lactate (Storage time 2 Days Lactate 5.1 6.7
mmol/l . Storage time 28 Days Lactate 25 31 mmol/l).
3- Fragility and abnormalities in the shape of RBC.
4- Deformability of Red Blood Cells (RBC) ,caused by ATP
content decreased, and depletion of 2.3 Diphosphoglycerate
(2,3 DPG) .
5- Left-shifted oxyhemoglobin dissociation curve(less
oxygen supply to tissues)
6- Extremely hemolytic.
7- Excessive Acidosis.

In open heart surgery in neonates and small children, the

cardiopulmonary bypass circuit priming volume are relatively
large in relation to the patients size and blood volume.
Therefore, customarily requires priming with autologous blood
components to maintain the optimal hematocrit level , and
avoiding the excessive hemodilution during the bypass.

241
 Otherwise ,excessive hemodilution at cardiopulmonary
bypass in neonates and small children is associated with an
exaggerated capillary leak affecting the function of many organ
systems .In addition, decrease of plasma colloid osmotic pressure
(COP) cause shift fluid from the intravascular space into the
interstitial space , thus augments total body water and increase
the risk of multiple organ failure(add human albumin during the
bypass helps in increase the colloid osmotic pressure to
appropriate level).
To avoid the deleterious effects of blood transfusion, and to
reduce the contact surface of blood with artificial materials, we
must reduce of the bypass circuit size. This will be achieved by
reducing the length of the CPB lines, reducing the diameter of
the CPB lines, using the lowest prime oxygenator and arterial
line filter, and pre-bypass crystalloid dilution during induction
should be avoided as well as return of the crystalloid cardioplegic
solution into the circulation.
Utilizing the lowest prime possible for pediatric is especially
important ,because of their particularly high cardiopulmonary
bypass circuit prime volume to patient blood volume ratio. This
ratio can be decreased by using small diameter(with the help of
vacuum assisted venous drainage) , very short tubing connections
by positioning the arterial roller-pump head close to the
oxygenator (between reservoir outlet and oxygenator inlet) and
the vent\ suction roller-pump heads close to the cardiotomy
reservoir inlet (by using a special version of heart-lung machine
which include smaller pump head with freely adjustable position
console) ,and keep the tube length as short as possible by
positioning the pump close to the surgical table operation.
Advantage of Vacuum-Assisted Drainage in set up:
Allows smaller inner diameter of venous line.
Allows smaller venous cannulas .
Allows higher position of the venous reservoir.

241
Specifications of the Circuit:
Short tubing.
Smallest inner diameter.
Smallest components. View Figure 8:4 .

Advantage of Smallest and Short Tubing:

Priming volume of less than 100 ml is possible.
It is possible to reduce or even completely avoid donor
blood transfusion.

242
Disadvantage of Short Tubing:
Draping by sterilization towels is necessary for sterility.
less visibility , the lines and oxygenator maybe covered
through the towels .
Decreased safety . View Figure 8:5 .

243
Characteristics of pediatric Heart-Lung Machine:
Mast-mounted pumps.
Small pumps.
Freely adjustable position . View Figure 8:6 .

Position of the Head pump:

Roller pump for suction and vent at height of the reservoir inlet.
Arterial pump between reservoir outlet and oxygenator inlet. View
Figure 8:7 .

244
Position of the Heart-Lung Machine:
Close to operation table.
Venous inlet at higher position.
Bubble detector prior to arterial line filter. View Figure 8:8 .

245
 Hypothermia and Hypothermic
Circulatory Arrest
Before going to cardiopulmonary bypass, the perfusionist
must determine many aspects of bypass technique such as
procedure temperature, and circulatory arrest possibility , as well
as prime constituents and the degree of hemodilution. However,
the decision that related of the specific minimum temperature for
patient during cardiopulmonary bypass and flow rate, including
the possibility of hypothermic circulatory arrest, should be
decided by the surgeon , due to his knowledge of the patient's
case, the steps that must be taken to repair, and factors to take
these decisions.

The ideal temperature degree for CPB is probably an

indeterminate , that varies with the physiologic goals. The issue
of using either normothermia or hypothermia in patients
undergoing open heart surgery has been discussed ,recent studies
have demonstrated that normothermia with warm continuous
cardioplegic techniques are associated with better post-operative
outcomes, and less complications after surgery . But another
studies shows that the hypothermia reduces tissue metabolic rate
and oxygen demand ,thus protect the myocardium and the brain
against potential ischemic insult as well as protection of other
vital organs. In addition, reduces tissue metabolic rate allows to
lower the arterial blood flow (increase ischemic tolerance) and
promotes better conditions in the operation field . The present
evidence does not support one temperature management strategy
for all patients, normothermia and hypothermia are commonly
used and regarded as equal and to decide which will be used is
the responsibility of the surgeon.

246
 Most open heart surgeries are performed under normal
temperature or moderate hypothermia 32-28 C. But there are an
interventions that require much greater extremes in temperature
(28-18C) especially in neonates and infants patients. So the risks
of gas embolism secondary to the changes in gas solubility which
occur with temperature change are greater. There are
physiological reasons to limit the rate of heating and cooling .
The most important of these is the risk of form gas embolism
when fully saturated blood are warmed too rapidly (due to the
decrease in gas solubility at higher temperatures). Furthermore,
the rapid rewarming causes desaturation of hemoglobin in
cerebral veins. Cerebral venous hemoglobin desaturation with
rapid rewarming is caused by an increase in cerebral metabolic
rate for oxygen (CMRO2) that is temporarily greater than the
increase in cerebral blood flow(CBF). This mismatch may
indicate a transient abnormality in flow-metabolism coupling, or
the effect of temperature gradients on oxygen transfer from
hemoglobin to brain.

The optimal difference between the water and blood

temperature have yet to be determined. Some studies suggested
to limit the temperature difference between the water (in the
heater cooler) and the venous blood temperature from 10-12C
in adult and 8C in pediatric. Limiting the temperature gradient
during rewarming minimizes the risks and helps to homogeneous
warming , which prevent the rapid temperature falls at the early
post bypass period. The maximum water temperature that should
be used does not exceed 42C, in this temperature the protein
denaturation occurs. The perfusate (arterial blood) temperature
should not exceed 38.9 C, the aggressive rewarming practices
may be contributing to cerebral injury.

247
 The previous constraints don't apply during cooling as some
investigators believe. It is common practice to lower the water
temperature as much as possible during the early phase of
cooling, often to as low as 4C. Thus there will be considerably
more than a 10C gradient between the water and blood
temperature during the cooling phase . But there are a studies,
against the very rapid cooling , due to other considerations during
cooling, relate to the shift of the oxyhemoglobin dissociation
curve to the left with rapid cooling(Increase the oxygen attached
to the hemoglobin, which means that the hemoglobin will retain
with oxygen ,and liberate small amount of oxygen to tissue). This
is further exacerbated by the use of an alkalotic pH strategy such
as the alpha stat strategy which is currently in widespread clinical
use for adults.

248
Heat Transfer during Cardiopulmonary Bypass

To achieve the desired body temperature of the patient

during cardiopulmonary bypass, a heat exchanger is integrated
into the oxygenator , the energy transfer into and out of the heat
exchanger is provided by nonsterile water that circulated through
a heater/cooler unit . When cooling is desired, the water is passed
through an ice bath in heater/cooler unit. If the patient is cooled
to less than 20 C the head must cooled externally with ice bags .
When warming is desired, it is heated by electric resistance
heaters in heater/cooler unit. Used the vasodilation drugs may
speed the rewarming process especially after deep hypothermia.

The heat transfer surface is usually made of stainless steel,

aluminum, or polypropylene, those materials have good thermal
conductivity and are readily coated with polymers to minimize
blood interactions. Most heat exchangers consist of a coiled
tubing, to increase heat efficiency of heat transfer. Heat exchange
is also enhanced in most devices by flowing the blood and water
in opposite.

241
 Temperature Monitoring

To achieve a degree of accuracy in monitoring the

temperature in patients undergoing open heart surgery , it is
important to use more than one site to measures the temperature
. The investigators recommended to employ three measures
locations at least to monitor the temperature in cardiac surgery
patients, this is due to the substantial variability that is noted in
central temperature readings and lack of the concordance of
central temperature measures in every patient.

It is important to use the temperature monitoring location

most likely to reflect cerebral temperature, because the brain is
more susceptible to harm due to hyperthermia. The most
commonly sites used to monitor the temperatures in cardiac
surgery patients include esophageal, rectal, bladder ,blood. The
bladder temperature may reflect core temperatures better than
rectal or esophageal.

251
 Advantages Hypothermia

1- Decreased metabolic rate to allows a safe reduction

of perfusion flow rate:
At normothermia, oxygen delivery depends on flow
rate, hematocrit and oxygen saturation of the perfusate.
There is a many studies concerning the effect of
hypothermia in reducing metabolic rate. Some studies show
that the reduce 7on patient temperature that cause to reduce
the metabolic rate about 50%.

Normal flow rate at normal temperature depends on

patient's age: in neonates 120200 mL/kg /minute, children
up to 10 kg 100170 mL/kg/min, older children 80120
mL/kg/minute, and in adults up to 50 75 mL/kg/min. At
hypothermia, the reduction of metabolic rate would allow a
temporary decrease in perfusion which might allow
intracardiac repair of congenital or acquired anomalies.
Minimum adequate perfusion flow rate under general
anesthesia at hypothermia has been calculated, the critical
flow rate at 27C is 3035mL/kg and at 18C 530
mL/kg (Kern et al., 1993).

The minimum flow rate is depending on the patient's

temperature, the following table shows the minimum flow
rate per meter square of body surface area.

251
 Table 37: Minimum Blood Flow Depending of
Patient Temperature
Hypothermia (C) Temperature Flow index

Mild hypothermia 3734 C 2.4 l/min/m2

Mild hypothermia 3432 C 2.2 l/min/m2
Moderate hypothermia 3230 C 2.0 l/min/m2
Moderate hypothermia 28 C 1.8 l/min/m2
Deep hypothermia 26 C 1.6 l/min/m2
Deep hypothermia 24 C 1.4 l/min/m2
Deep hypothermia 22 C 1.2 l/min/m2
Deep hypothermia 20 C 1.0 l/min/m2
Deep hypothermia 18 C 0.8 l/min/m2
Profound hypothermia 16 C 0.6 l/min/m2

The reduction of perfusion blood flow during hypothermia

improves the intracardiac exposure: Many patients with
congenital cardiac diseases, especially those which result in
cyanosis, will develop multiple profuse aortopulmonary
collateral vessels which increase the left heart return, increased
pulmonary venous return (back flow). This back flow commonly
returns through the pulmonary veins to the left atrium , resulting
in limit of exposure in surgical field . In addition, when the
pulmonary artery is open it will also result in continuous back
flow from the pulmonary arteries.

252
 The excellent intracardiac exposure is necessary and very
important . Excellent intracardiac exposure can be accomplished
by reducing the amount of left heart return temporarily, thus
allowing the surgeon to do the surgical repair properly .
Reducing the amount of left heart return can be achieved very
effectively by reducing the perfusion flow rate with using
hypothermia.

The degree of hypothermia used during cardiopulmonary

bypass surgery depends primarily on the reduction in flow
required to perform an accurate repair. This include mild
hypothermia (3732C), moderate hypothermia (3128 C) ,deep
hypothermia (2718C) or profound hypothermia (>18 C). Each
of this temperature can be employed ,this depend on the steps
that must be taken to repair , and the length of procedures.

Mild hypothermia can be used in many simpler repairs ,

where the period of cross-clamp (myocardial ischemia) is
relatively short. Otherwise , in more complex procedures,
moderate or deep hypothermia allows for longer periods of aortic
cross-clamp and temporary periods of lower flow with
maintenance of adequate myocardial protection. During core
cooling furosemide (lasix) 1 mg/kg is administered if urine flow
falls below 1 ml/kg/30min. Calcium chloride (100 mg/kg) is
administered before termination of bypass for its inotropic effects
and to increase the blood calcium level

In the following table some of the pediatric proposed

temperatures depending on the length and complexity of the
procedures.

253
 Table 38: Environments of Most Common Procedures
Temperature Type of Venous Cannulation Cross Sump LV
Procedure Clamp Root Vent

BT Shunt 37C Single Cannula(single-stage): RA NO NO NO

RV-PA conduit Single Cannula(single-stage): RA NO \
3735C NO NO
(Contegra or Hancock) or Two Cannula: SVC+IVC YES

TCPC Three Cannula: single-stage: RA +

3735C NO NO NO
Extra-cardiac Conduit Two Curved Cannula: SVC+IVC

Bidirectional Glenn 3735C Two Curved Cannula: SVC+IVC NO NO NO

ASD secundum 36C Two Cannula: SVC+IVC YES YES NO

SAM 3734C Single Cannula(single-stage): RA YES YES YES

ASD Sinus Venosus 3534C Two Cannula: SVC+IVC YES YES NO

PAPVR 3534C Two Cannula: SVC+IVC YES YES NO

Sub Aortic Stenosis 3534C Single Cannula: RA YES YES YES

CABG 3534C Single Cannula (two-stage): RA YES YES YES

VSD 32C Two Cannula: SVC+IVC YES YES YES
AVR 32C Single Cannula: RA YES YES YES
Single Cannula: RA
MVR 32C YES YES YES
or Two Cannula: SVC+IVC
YES/
TVR 3532C Two Cannula: SVC+IVC YES YES
NO
Tetralogy of Fallot 32-28C Two Cannula: SVC+IVC YES YES YES
Ebsteins Anomaly 32-28C Two Cannula: SVC+IVC YES YES YES

Three Cannula: single-stage: RA +

TCPC lateral tunnel 32-28C YES YES NO
Two Curved Cannula: SVC+IVC

Three Cannula: single-stage: RA +

Senning (Atrial Switch) 32-28C YES YES YES
Two Curved Cannula: SVC+IVC
Truncus Arteriosus 3226C Two Cannula: SVC+IVC YES YES YES

Arterial Switch-ASD 3024C Two Cannula: SVC+IVC YES YES YES

TAPVR 28-24C Two Cannula: SVC+IVC YES YES NO

Ross Procedure 2226C Two Cannula: SVC+IVC YES YES YES

Arterial Switch-VSD 2226C Two Cannula: SVC+IVC YES YES YES
Norwood 18C Two Cannula: SVC+IVC YES YES YES
Interrupted Aortic Arch 1826C Two Cannula: SVC+IVC NO NO NO

254
 2- Allow complete circulatory arrest of cardiopulmonary
bypass if the need arises:
Deep hypothermic circulatory arrest(DHCA) involves
complete stopping of perfusion at a core body temperature
of less than18C.
The safe circulatory arrest time during deep hypothermia
(18 C) is between 15 and 40 min. Safety is defined as the
absence of any structural or functional damage as a result of the
procedure. In practice at 18 C, 30 min is regarded as completely
safe, whereas 40 min has only a 90 per cent probability of safety .
Otherwise , during the process can go to circulatory arrest for
temporary periods of time, that depending on the temperature. as
shown in the tables.

Table 39: Arrest Period as the Patient Temperature

Hypothermia Level Patient Temperature(C) Arrest Period
Mild 32 Under 10 min
Moderate 28 10-15 min
Deep 18 15-40 min
Profound <18 40-60min

Table 40: Effect of temperature on cerebral metabolic rate

and safe circulatory arrest duration
Cerebral Metabolic
Temperature Duration of safe
Rate(CMR)
(C) Circulatory Arrest (min)
(% baseline)
37 100 5
32 70 8
30 60 10
28 50 12
25 40 15
20 30 25
18 20 40
15 15 60

255
3- Improved myocardial protection:
Hypothermia reduces the metabolic demands of the
myocardium and other body organs. The local myocardial
hypothermia can be attained by infusion of cold cardioplegia
solution. But the temperature of the perfusate has an
important effect on the rate of rewarming of the heart,
especially if partial cardiopulmonary bypass is used. For
example when a single venous cannula is used, the blood will
enter the right ventricle thus contribute to rewarming of
ventricular myocardium and ventricular septum. Even when
total cardiopulmonary bypass is used the temperature of
retrocardiac tissues ( which will be determined by perfusate
temperature) will affect the rate of myocardial rewarming.
With normothermia a multiple dose of cardioplegia
solution must be infused for myocardial protection, in the
neonate and younger infant many studies have suggested that
multiple re-infusions of cardioplegia result in less good
myocardial protection, most probable because of myocardial
edema. Use of a lower degree of whole body hypothermia
allows for more effective maintenance of myocardial
hypothermia with a single infusion of cardioplegia.
4- Low flow decreases the inflammatory response to
bypass:
Hypothermia per se reduces the inflammatory effects of bypass
including cellular activation and reduced activation of many
humoral cascades. Otherwise , the higher perfusion flow rate
during normothermia results in a greater degree of activation of
the cellular components of blood and humoral cascades ,
because the higher flow rate led to exposure a greater volume of
blood to the internal surface of cardiopulmonary bypass circuit
(tubing , oxygenator, heat exchanger , filters and reservoir ) . In
addition, the increase of perfusion flow rate results in increase
in the amount of blood which is dragged by the pump sucker
and sump . The pump suckers and sump are primary sites of
inflammatory activation. Thus ,the use of a reduced flow rate
during hypothermia reduces the inflammatory response in
addition to the reduced inflammatory response that results from
hypothermia per se.
256
 Disadvantages of Hypothermia
1- Prolongation of Cardiopulmonary Bypass: Use of a more
severe degree of hypothermia during bypass requires longer
periods of cooling and rewarming, that results in a greater
aggregation of the deleterious effects of cardiopulmonary
bypass. The rate of cooling and rewarming on cardiopulmonary
bypass depends on the efficiency of the heat exchanger,
temperature gradients between the water and blood , body
temperature ,type of oxygenator, and the mass of the patient (fat
has a relatively poor blood supply , obese patients require
longer periods of cooling and rewarming). Generally the babies
can be cooled and rewarmed rapidly more than adult patients.
2- Bleeding: Hypothermic bypass together with hemodilution
may disturbs the coagulation system, therefore is assumed to be
responsible for increasing the probability of postoperative
bleeding. This may be related to the effects of hypothermia on
platelet function, also the effect of bypass per se on platelet
function. But therefore bleeding , should not be considered a
reason to avoid hypothermic bypass, the data do not clearly
demonstrate that hypothermic patients have greater
postoperative bleeding and transfusion requirements.
Furthermore use of platelet and antifibrinolytic agents can be
effective in reversing the deleterious effects of bypass and
hypothermia on platelet function and coagulation.
3- Prolonged Postoperative Recovery: Use of deep bypass
hypothermia often results in patients returning to the intensive
care unit with a considerable heat debt, they are likely to remain
hypothermic for several hours, thus may prolongs postoperative
recovery in the intensive care unit. To avoid the rapid
temperature falls at the early post bypass period after deep
hypothermia ,the patient can be warmed more effectively with
maintaining a limited temperature gradient (8-10) during
rewarming to ensure a homogeneous warming, and sustainability
of heating for a period of ten minutes at least after arrival to
normal temperature.
257
 Cerebral Blood Flow

258
 Cerebral Blood Flow
Cerebral perfusion is a cardiopulmonary bypass technique that
uses special cannulation procedures to perfuse only the brain during
hypothermic circulatory arrest to protect the brain from hypoxic
ischemic injury , and therefore extending the period of safe deep
hypothermic circulatory arrest. The advantages of cerebral perfusion
include continuous cerebral cooling, cerebral substrate delivery, and
removal of particulates and toxic metabolites. The brain represents
about 2% of total body weight , but receives almost 15% - 30% of
cardiac output. Brain tissue constantly maintains an extremely high
metabolic rate. At rest, the brain consumes oxygen at an average
rate of 3.5 mL/100 g of brain tissue/min , which represents nearly
20% of total body oxygen consumption(This is often referred to as
the cerebral metabolic rate for oxygen or CMRO2 ).The high
metabolic rate must be matched by high blood flow supply, this
making airtight regulation of cerebral blood flow and oxygen delivery
critical for survival.
The brain is able to tolerate very short periods of ischemia (lack
of blood supply). This because the energy production in nerve cells
are almost entirely by oxidative metabolism of substrates including
glucose and ketone bodies, with very limited ability for anaerobic
metabolism , also the brain generally does not have ability to store
energy. Without oxygen, energy dependent processes cease leading to
irreversible cellular injury if blood flow is not re-established quickly
(3 to 8 minutes under most conditions) Therefore, continuous blood
supply is absolutely required for brain function, sufficient cerebral
blood flow must be maintained to ensure a constant delivery of
oxygen, and substrates and removal of metabolic waste.

Table 41: Basic of Cerebral Blood Flow

Normal Cerebral Perfusion Pressure(CPP) = 80 - 100 mmHg .
Cerebral venous PO2 = 32 - 44 mmHg.
Cerebral venous SO2 = 55% - 70% .
Intracranial pressure (supine) = 10 - 15 mmHg.
Cerebral metabolic rate of oxygen(CMRO2) = 3 - 3.5 mL/100 g/min.

251
 Cerebral Hemodynamics
Cerebral blood flow (CBF) is driven by cerebral perfusion
pressure (CPP), represented by the difference between mean
arterial blood pressure (MAP) and intracranial pressure (ICP).
According to Ohms law, flow is directly related to perfusion
pressure (inflow minus outflow) and inversely related to
cerebrovascular resistance. Ohms law states that flow is
proportional to the difference in inflow and outflow pressure
(P) divided by the resistance to flow (R):

In the brain, Pressure(pressure differential) is synonymous

with the cerebral perfusion pressure (CPP. It must be maintained
within narrow limits because too little pressure could cause
inadequate blood flow to brain tissue , and too much could raise
intracranial pressure (ICP) resulting in cerebral edema.
Blood flow is also estimated by Poiseuilles law that states
that flow is directly proportional to the pressure differential (P),
and the fourth power of the vessel radius (r4); and inversely
proportional to the length of the vascular(L) , and the blood
viscosity .

Blood viscosity normally does not change very much (except

when hematocrit and\or temperature changes) .Also, vessel
length does not change significantly in vivo (assumed to be
constant). Thus, vessel diameter (radius) is the most powerful
determinant of blood flow and even small changes in vessel
diameter have significant effects on cerebral blood flow. The
reason for this is that small changes in vessel diameter lead to
large changes in resistance to alter cerebral blood flow. For
example, a 2-fold increase in radius decreases resistance by 16-
fold! Therefore, very small increase in radius dramatically
increase cerebral blood flow
261
 Control of Cerebral Blood Flow
The regulation of cerebral blood flow at hypothermic on
cardiopulmonary bypass circulatory arrest is dependent on a
number of factors that can be divided into:
a. Metabolic Rate(Temperature): Cerebral metabolic rate
(CMR) decreases by 5% to 7% per degree Celsius of
temperature reduction, decrease the temperature to 18 C can
cause complete suppression of the electroencephalography
(EEG). Cerebral metabolic rate of oxygen at 18 C is less
than 10% of normothermic control values, which likely
accounts for the brains tolerance of circulatory arrest for
moderate periods at these temperatures.
b. Blood Viscosity: Hemodilution during cardiopulmonary
bypass reduces blood viscosity and increases cerebral blood
flow.
c. Vasoactive Drugs (the radius of cerebral blood
vessels): The majority of the drugs used to lower systemic
(Systemic vasodilators) blood pressure also induce cerebral
vasodilation and increases cerebral blood flow.
d. PaCO2: PaCO2 is an independent determinant of CBF
during bypass. Every 1 mmHg change (increase or decrease)
in PaCO2 alters CBF approximately 3%. Decrease the
PaCO2 results in cerebral vasoconstriction, and decreased
cerebral blood flow(CBF). Increase the PaCO2 results in
cerebral vasodilation and increases CBF. The effect of CO2
and alpha-stat/pH-stat strategies becomes increasingly
relevant below 27C.
e. Anesthetics: Approximately 60% of cerebral energy
consumption is used to support electro physiological
function. Cerebral metabolic rate is directly proportional to
neuronal activity. Generally the anesthetics cause decrease in
cerebral metabolic rate (CMR), with the exception of
ketamine and Nitrous oxide (N2O).
261
f. Cerebral perfusion pressure:
1- Antegrade cerebral perfusion (ACP): Antegrade cerebral
perfusion (ACP), was devised as a perfusion method that
used during complex cardiac operations, which need deep
hypothermic circulatory arrest (DHCA), to provide cerebral
oxygenated blood through the innominate artery (Direct
cannulation of the arch vessels) or right subclavian artery,
to provide more time to the surgeon to do the procedure. View
Figure 8:9 .

262
 The cannulation techniques for antegrade cerebral perfusion
(ACP) have varied. The cannulation often done in the innominate
artery, the left subclavian artery and left carotid artery are snared.
The arterial flow commenced maintaining a perfusion
pressure (measured in the right radial artery) of 5070 mmHg.
During antegrade cerebral perfusion the upper limbs are supplied
also by arteries arising from the innominate and subclavian
arteries. View Figure 8:10 & Figure8:11 .

263
264
 During Norwood procedure, the arterial cannula may be
placed in the main pulmonary artery, cerebral perfusion flows
from the pulmonary artery through the right modified Blalock-
Taussig shunt, the right and left pulmonary arteries are occluded
by snares. View Figure 8:12.

265
 Alternative antegrade cerebral perfusion techniques include
cannulation of the right subclavian artery and hemicerebral
perfusion via the right axillary artery. these technique often used
in patients with Type A aneurysms , or in cases where calcified
aorta could affect the neurologic outcome. View Figure 8:13.

266
2- Retrograde cerebral perfusion (RCP)

Retrograde cerebral perfusion (RCP): is supplying cold

oxygenated blood to the brain into the superior vena cava by
reversing the direction of blood flow in the superior vena cava.
(View Figure 8:14) .via an arterial-venous shunt (constructed in the
CPB circuit between the arterial and venous line) .The cava are
snared and arterial blood directed from arterial line via the A-V
shunt to venous line through the SVC to brain (Reservoir inlet
and the inferior vena cava cannula was clamped).
Pump flows are started with a mean perfusion pressure of 25
mmHg via an internal jugular line . During retrograde cerebral
perfusion a significant extra cranial shunting via the external
jugular veins may occur, that make the retrograde cerebral
perfusion delivery at pressures less than 40 mmHg possible and
safe.

267
 The retrograde cerebral perfusion supplies the upper limbs
with oxygenated blood also by veins rising from the superior
vena cava. View Figure 8:15.

268
 Alternative retrograde cerebral perfusion include cannulation
of the SVC with another arterial cannula which constructed in the
arterial line via Y- connection. At the beginning of bypass,
femoral arterial cannula is used ,and a large single venous
cannula is placed in the right atrium, after cooling the patient to
arrest temperature the venous cannula is replaced by the second
arterial cannula, femoral arterial cannula is occluded. The
superior vena cava are snared and arterial blood directed from
arterial line via the Y-connection through the SVC to brain.
Cerebral blood return through the arch vessels. View Figure 8:16.

261
 Calculating the Adequate Amount of CBF
Calculating the Adequate Amount for separate blood flow to any
organ in body depend on prior knowledge about the directed percentage
of blood flow to that organ from the total of cardiac output. See Table 42.

Table 42: The Directed Percentage of Blood Flow to Organs from

Cardiac Output
Organ Infants Adults
Brain 34% 15%
Coronary (Heart) 3% 5%
Splanchnic organs(Liver, Spleen, Pancreas, GI tract) 25% 28%
Renal ( Kidneys ) 18% 25%
Muscle 10% 12%
Fat 5% 5%
Flow to poorly perfused tissue 5% 10%

The adequate amount of blood flow decreases with each decrease in

the patient temperature. Although many authors have reported that the
adequate amount of blood flow in cerebral perfusion about 1020 ml/kg,
but the variations in arrest temperature make the determine of adequate
amount of cerebral perfusion flow depend on patient's temperature. See
Table 43 .

Table 43: Cerebral Blood Flow Depending of Patient Temperature

CBF = Index Flow Average percentage from flow Directed to brain (15%-34%)
Temperature CBF = BSA Temperature Cardiac index x ( 15%-34% )
3437 C BSA 2.4 (15%-34%) In modern devices such as Stockert s5 you
3234 C BSA 2.2 (15%-34%) don't need to calculate CBF , just enter the
BSA setting (patient height and weight) ,
3032 C BSA 2.0 (15%-34%)
and set the flow factor (the appropriate
28 C BSA 1.8 (15%-34%)
cardiac index depending on patient's
26 C BSA 1.6 (15%-34%) temperature ) in machine control-panel
24 C BSA 1.4 (15%-34%) (Central Control Monitor) ,and by selecting
22 C BSA 1.2 (15%-34%) the relative flow from flow display in the
20 C BSA 1.0 (15%-34%) arterial pump screen you can see the
18 C BSA 0.8 (15%-34%) percentage of your flow on the head pump
screen ( CBF = 15%-34% based on the
16 C BSA 0.6 (15%-34%)
patient age).m

271
 Modified Ultrafiltration
Modified ultrafiltration (MUF) is a technique used by several
clinical centers to remove the fluid overload and inflammatory
mediators from the patients circulating blood volume and the
residual volume in extracorporeal circuit after termination of
cardiopulmonary bypass.
One important factor affecting morbidity and mortality after
cardiac surgery in neonates, infants, and young children is the
effect of CPB. At beginning of cardiopulmonary bypass a
considerable hemodilution may occurs, as a result of the
disproportionate exposure to the circuit (relative to their body
size) via priming volume which is required to de-bubble the
CPB circuit. Hemodilutional effect includes decreasing blood
viscosity, increase the tissue edema, and organ dysfunction.
Another significant effect of CPB is the inflammatory response
that occurs due to the exposure of blood elements to the non
endothelialized circuitry of CPB. This inflammatory response
leads to an increase in capillary permeability, leading to an
overall increase in tissue edema postoperatively. Efforts to
reduce the hemodilution and inflammatory effects of CPB have
included reducing priming volume, perioperative anti-
inflammatory and diuretic therapies, and the use of the methods
of hemoconcentration.
Presently there are two methods of hemoconcentration.
Conventional hemoconcentration during CPB and modified
ultrafiltration (MUF) after CPB. In the conventional
hemoconcentration method, the hemoconcentrator is installed in
the CPB circuit ,the inlet positioned with any port after arterial
pump, to concentrate the blood during CPB, and return it through
the hemoconcentrator outlet which is positioned in the venous
reservoir. In the Modified ultrafiltration (MUF) method,
hemoconcentration is performed after discontinuation of CPB by
means of a pump, suctioning the blood from the arterial, flowing
through the hemoconcentrator to concentrate the blood (include
filtration of the mediators of general inflammatory reactions) and
returned it to the patient through the right atrium.
271
 Technique of MUF

After a separation from CPB, the patient remained

heparinized. The venous line is interrupted temporarily and the
venous cannula is removed .The blood in venous tubing will be
returned to the venous reservoir. The MUF outlet line catheter
placed in the right atrium. The MUF inlet line positioned in the
CPB circuit in the outlet of cardioplegia pump. The MUF is
primed with the blood form the CPB circuit during the
rewarming period of the CPB. After weaning from CPB, blood is
drawn retrograde from the arterial cannula with the help of
cardioplegia pump as well as from the venous reservoir through
the oxygenator . MUF is started by allowing the arterial blood to
flow from aortic cannula to the hemofilter, at a rate of 1015
ml/kg/min, which is controlled by the cardioplegia pump. If a
vacuum is applied to the filter port of the ultrafilter, that result in
an increase in the ultrafiltration rate of 100 to 150 mL per
minute. The concentrated blood is re-infused into the right atrium
through the MUF line. Application of modified ultrafiltration for
1020 minutes after bypass can increased the patients hematocrit
levels from 25% to 35% . Modified ultrafiltration will be
completed either when the CPB reservoir emptied (All the left
over blood in the CPB circuit is chased out with crystalloid
solution by the arterial pump to MUF pump) or when the
ultrafiltrate volume reached the preset goal . During the MUF,
the arterial cannula is removed. The blood in the arterial tube will
be returned to the patient . At the conclusion of procedure, the
MUF catheter in the right atrium is removed and protamine is
administered. View Figure 8:17.

272
Advantages of Modified Ultrafiltration
1- Removal of excessive body water and decrease the
hemodilution effects that is associated with the institution of
CPB. In addition, the raised in hematocrit after
cardiopulmonary bypass, that lead to enhancing oxygen
delivery to the tissues.
2- Delivering oxygenated blood in the pulmonary circulation,
which lead to reduction in the pulmonary vascular
resistance.
3- Decrease the necessity of blood and blood component
transfusions in the postoperative period.
4- Remove the mediators of general inflammatory reactions
which is associated with CPB, by reducing circulating
cytokines, which are associated with capillary leak
syndrome.
5- Reduction in the quantity of circulating endotoxins.

273
Disadvantages of Modified Ultrafiltration
1. The risk of air embolism formation in systemic organs .
2. The need to maintain heparinization during the period of
ultrafiltration.
3. The additional time required in the operating room.
4. The arterial cannula must be left in place during the MUF
,that may cause obstruction of the ascending aorta,
especially in a small ascending aorta.
(As alternative , the venous and arterial cannulas can
remove, and a double-lumen MUF catheter placed in the
right atrium)
5. The necessity of an additional complicated circuit.

In some centers, the modified ultrafiltration is not used ,

because the technique in this centers involves use of a high
hematocrit (3035%) during cardiopulmonary bypass . This can
be achieved by reduced prime volume ,as well as application of
conventional ultrafiltration during the latter phases of rewarming
to increase the hematocrit to even greater than 35% , prior to
weaning from cardiopulmonary bypass.

274
275
 ter 9
Myocardial
protection

Chapter 9
Myocardial
protection
276
277
 Myocardial protection
One of the major concerns during cardiac surgery is
protection of the heart during the operation. Diseased hearts have
low energy reserves and are especially susceptible to further
ischemic injury.
Maintain the myocardial function
The myocardium obtains high-energy phosphates in the
form of ATP through aerobic metabolism. In the presence of
oxygen, the heart can utilize free fatty acids, glucose ,amino
acids, and ketone bodies as the source of energy for the formation
of ATP. In the presence of oxygen, the heart generates 36 moles
of ATP from one mole of glucose.
During open-heart surgery a cross-clamp is placed across the
ascending aorta above the coronary ostia and proximal to the
aortic cannula to provide a dry and motionless operative area,
thus isolating the coronary circulation and preventing oxygenated
blood entering to the myocardium .Under this anaerobic
conditions, glucose is converted to lactate to generates just two
moles of ATP for every mole of glucose. In addition to this lower
level of efficiency, lactic acid and hydrogen ions accumulate in
the tissues, which inhibit glycolysis and many other cellular
functions .Therefore, myocardial protection techniques are used
to maintain the myocardial function and prevent myocardial
damage during the period of ischemia associated with
cardiopulmonary bypass. This can be achieved by decreasing
myocardial metabolic rate during the ischemia period by:
1- Stopping electrical and mechanical activity of myocardial:
Potassium in the cardioplegia solution blocks the initial phase
of myocardial depolarization, resulting in diastolic
electromechanical arrest (stopping of electrical and
mechanical activity).

278
2- Localized hypothermia of the cardiac muscle: hypothermic
myocardial preservation through cold cardioplegic solution (blood
cardioplegia or crystalloid alone), ice slush or cold topical saline placed
in the pericardial space by the surgeon, or cooling screen covered around
the heart.

The heart has a high metabolic demand, and a high level of oxygen
extraction. To minimize the injury sustained by the heart, myocardial
protection strategies should focus on the ratio of myocardial oxygen
demand to myocardial oxygen supply (Myocardial oxygen balance). View
Figure 9:1.

Oxygen Extraction Ratio (OER) is the ratio of oxygen consumption (demand) to oxygen delivery(supply).

Oxygen Content: amount of oxygen carried in the blood, both arterial(CaO2) and venous(CvO2).
1.38: amount of O2 that can combine with 1 gram of hemoglobin.
0.0031: solubility coefficient of O2 in the plasma.

271
 Cardioplegia

Cardioplegia-based techniques remain the basis of myocardial

protection, the aims being: rapid induction of diastolic arrest;
minimization of energy requirements during ischemia; prevention of
damage caused by absence of blood flow; and prevention of damage
caused by reperfusion. (JOHN WC ENTWISTLE III AND ANDREW S WECHSLER) .

Cardioplegia is a potassium solution used to cause rapid diastolic

cardiac arrest without any electrical or mechanical activity by providing
an environment of excess extracellular potassium ions thus abolishing the
transmembrane gradient of potassium and inhibiting repolarization.

The effectiveness of cardioplegia is observed via the absence of any

apparent electrical activity on the ECG. Over time(15-20 minutes)
cardiac repolarization is possible by normal metabolic mechanisms
present within the cell. This cardiac repolarization occur due to the
ability of the myocardium to utilize anaerobic pathways for energy
production. This results in depletion of energy reserves and accumulate
products of anaerobic metabolism, such as lactic acid. Therefore if
cardioplegia is not given, ventricular fibrillation or contractions could
occur at a variable period during the surgical operation and thus deplete
energy stores(ATP).
The delivery of cardioplegia may be as a single dose, multidose or
continuous infusion. Continuous cardioplegia administration would
improve myocardial protection but this is not always possible.
Multidose cardioplegia delivery (every 15-20 minutes) allows a
relatively bloodless surgical view, and maintain the heart arrested ,
hypothermic, improve preservation of ATP ,and reduces the development
of intramyocardial acidosis and production of carbon dioxide.
The surgeon should be informed after 20 minutes since of last dose
of cardioplegia was delivered. If cardioplegia cannot be immediately
delivered, the surgeon usually inform the perfusionist when remind him
again.
281
 Types of Cardioplegia
1- Cold Crystalloid Cardioplegia: The crystalloid
cardioplegia solutions used for many years, consisted of
crystalloid solutions with potassium and various additives
(e.g. Calcium, in low concentration, to maintain integrity
of cell membranes. Magnesium may help stabilize the
myocardial membrane .Procaine, a local anesthetic, in low
concentration, to counteract the vasocontrictive effects of
particulate contaminants in the infusion and so promote
even distribution).
The initial dose typically contains a higher potassium
concentration (approximately 20 to 30 mEq/L) than
subsequent maintenance doses (approximately 5 to 10
mEq/L) to avoid systemic hyperkalemia.
Disadvantages of crystalloid cardioplegia: Inhibits
the enzyme Na+/K + adenosine triphosphate, which is
intrinsic to the function of transmembrane ion pumps,
thereby producing myocardial edema and consequent
activation of platelets, leukocytes and complement.

2- Cold Blood Cardioplegia or Warm Blood Cardioplegia:

Blood cardioplegia largely replaced crystalloid

cardioplegia in most centers. It mostly consists of four
parts of blood to one part crystalloid cardioplegia solution
(Normal saline 500ml with 40 mEq potassium). Blood
cardioplegia maintains oncotic pressure.

281
 Blood Cardioplegia delivery pump: (Double roller pump)
contains two segments of tubing, one for blood and the other for
the crystalloid component of cardioplegic solution. Those tubes
often have different diameters, inch for blood and 1/8 inch for
crystalloid cardioplegia .Cardioplegia delivery systems can
delivers a precise doses of potassium-containing blood that can
be adjusted over a wide range of delivery concentration (1:1 ,
2:1 , 4:1 , 8:1 , ).

Advantages of blood cardioplegia are: Limits myocardial

injury by delivering oxygen to the cardiac cell, reduces
myocardial edema. In addition, the blood contains beneficial
substances, such as free radical scavengers, buffers, metabolic
substrates.

282
 Delivery Sites for the Cardioplegia
The cardioplegia delivery sites vary according to surgical
preference, and include antegrade and retrograde techniques:
1- Anterograde approach, via the aortic root, direct in coronary
ostia, or coronary grafts ( saphenous vein graft or arterial bypass
graft):
Antegrade administration is most commonly undertaken
through the placement of a cardioplegia cannula(short needle tip
cannula) into the aortic root near the aortic valve. The aortic
valve and the aortic cross clamp prevent flow in either direction
and thus force the cardioplegia into the coronary arteries.
The cardioplegia infusion must be evenly distributed
throughout the myocardium to be effective . The antegrade route
of cardioplegia delivery can be inadequate (uneven distribution)
in the presence of coronary artery stenosis disease or aortic
insufficiency. Coronary stenosis, led to prevent full delivery of
cardioplegia, to the regions of the myocardium. Aortic
regurgitation, led to lowers aortic root pressure, so reducing the
perfusion pressure of cardioplegia infused into the aortic root,
and also causes loss of cardioplegia into the left ventricle.
In the presence of aortic insufficiency, direct ostial
cannulation of the coronary arteries through the open aortic root
can be used to ensure the delivery of cardioplegia and uniform
cooling. Further, the under perfused area can be grafted early by
coronary grafts, and cardioplegia administered through the graft.
2- Retrograde approach via the coronary sinus, if severe
coronary artery occlusions exist.
An alternative or supplement to antegrade perfusion is
retrograde coronary artery perfusion. Retrograde coronary sinus
perfusion involves placing a balloon-tipped catheter through the
right atrium and guided into the coronary sinus. The balloon on
283
the catheter tip is either inflated manually (it requires inflation of
the cuff by using syringe before delivering cardioplegia) or is
self-inflating to prevent reflux of the cardioplegia into the right
atrium.
Retrograde cardioplegia is administered into the coronary
sinus, and provides flow to the myocardium in a retrograde
fashion through the coronary veins in reverse direction of normal
blood flow . It allows perfusion of areas of the myocardium
inaccessible through the antegrade route because of obstructing
coronary artery disease or aortic insufficiency.
Retrograde cardioplegia often is used to overcome the
potential for inadequate myocardial preservation ,to ensure
adequate left ventricular distribution of cardioplegia beyond
coronary blockages, and during aortic valve replacement to avoid
direct coronary ostial delivery routes.
Antegrade and retrograde techniques can be used
independently or together, depending on the needs of the patient
and the preference of the surgeon. Retrograde delivery is
associated with inadequate perfusion of cardioplegia to all
regions of the heart ,especially the right ventricle . The combined
use of both techniques through the delivery of both anterograde
and retrograde cardioplegia may ensure adequate distribution and
subsequent improved myocardial protect.
Complications of retrograde coronary sinus perfusion
technique comprise rupture of the coronary sinus from the
catheter tip and poor protection of the right ventricle .The poor
protection of the right ventricle is caused by placing the tip of the
catheter beyond the right ventricle veins draining, or when those
veins empty directly into the right atrium.
Often, when both antegrade and retrograde routes of
cardioplegia are used together, the myocardium is arrested with
an initial dose of cardioplegia given through the antegrade route,
then subsequent doses given in a retrograde fashion while
additional antegrade cardioplegia can give down each completed
bypass graft. Sometimes, simultaneous administration of
antegrade and retrograde cardioplegia are used.
284
 Cardioplegia Flow Rates and Pressures
Cardioplegia delivery depends on the mode of delivery and
the stage of the operation.
1- Antegrade cardioplegia: is given via the aortic root to the
coronary ostia at approximately 100 to 150 mL per body surface
area(m)/minutes (approximately 250-350 ml/ minutes for
adult), at a line pressure of 125-250 mmHg (Aortic root
pressure: 50-90 mmHg).

Patients with aortic valve insufficiency may need direct

aortic coronary ostia cannulation. The ostia pressure should not
exceed 100mmHg of pressure for the right coronary artery
(RCA) and the left main ostia should not exceed 200mmHg
pressure. When delivering via the saphenous vein graft to a
coronary artery, the pressure should be monitored closely and
should not exceed 100mmHg for the graft.

2- Retrograde cardioplegia: is given through a cannula placed

into the coronary sinus, And delivered at approximately 100 to
200 ml/minutes(depending on line pressure and sinus pressure)
and coronary sinus pressures ranging from 30 - 50 mmHg.
Monitoring of coronary sinus pressures during retrograde
administration is used to assess catheter placement: High
coronary sinus pressure can indicate that the catheter is up
against a coronary vascular wall (too far advanced) potentially
endangering coronary sinus integrity. Low coronary sinus
pressures can indicate the catheter is not in the coronary sinus
but is most likely in the right atrium, resulting in poor coronary
sinus perfusion.

285
 Initial Dosages of Cardioplegic Solution
Dosages of cardioplegic solution often are based on patient
weight (10 15 mL/kg when used a high potassium
concentration , or 20 - 30 mL/kg if used a low potassium
concentration ) . When blood cardioplegia is used, the initial dose
typically contains a higher potassium concentration (1:4) than
subsequent maintenance doses (1:8) to avoid systemic
hyperkalemia.
(Note: Cardioplegia temperature: approximately 7 to 12 C)
Cardioplegia Delivery Systems
The cardioplegia delivery system contains an infusion
system, heat exchanger cardioplegic for cold and warm
perfusion, and temperature monitoring port. The water source for
this heat exchanger is independently regulated from the one used
for the oxygenator that controls body temperature.
Warm Blood Reperfusion (Hot Shot)
Hot shot is warm pure oxygenated blood may be infused
before removing cross clamp to wash out waste products and
cardioplegia components, and to optimize the metabolic rate of
repair to make the heart ready to re work . While some prefer to
give the last shot as a cold cardioplegia to make zeroing to heart
before it re work again. Hot shot is generally delivered
retrogradelly at 150 - 200 ml/ minutes at a temperature of 32 -
37oC. The usual warm perfusion dose is 200 - 600 ml.
Side Effect of Cardioplegia Solutions: is an
increased incidence of atrioventricular heart block due to
intramyocardial hyperkalemia. This heart block usually resolves
in 1 to 2 hours and can be treated temporarily by use of an
artificial cardiac pacemaker. Intramyocardial hyperkalemia also
produces decreased myocardial contractility. Systemic
286
hyperkalemia can occur when coronary sinus blood containing
cardioplegia solution is returned to the oxygenator for subsequent
circulation. Decreased renal function during cardiopulmonary
bypass will also contribute to hyperkalemia. If hyperkalemia
persists at the conclusion of cardiopulmonary bypass, regular
insulin (10 to 20 units IV) can be given in combination with
glucose (25 to 50 mg IV) in an attempt to shift potassium into the
cells. Alternatively, furosemide can be used. The perfusionist can
also add crystalloid solutions to the bypass circuit and then use a
hemoconcentrator to ultrafiltrate the blood and thereby eliminate
potassium.

287
281
 Intra-Aortic Balloon Pump
Intra-Aortic Balloon Pump: Is a device that increase
myocardial oxygen delivery by diversion of cardiac blood
flow(mechanically displacement during balloon inflation) to
the vital organs(Coronary & carotid circulation), and decrease
in myocardial oxygen demand by decreasing the work load on
the left ventricle by decreasing the aortic end diastolic
pressure(Afterload) via the sudden decrease of pressure in
aorta after balloon deflation.
The Intra-Aortic Balloon Pump device consists of two
main parts: Intra-aortic balloon catheter that is inserted into
the aorta, and a machine outside the body. View Figure 10:1.

The balloon is connected to a console that regulates the

inflation and deflation of the balloon with the passage of
helium. Helium is used because it is easily dissolved in blood
and prevents the risk of air emboli if the catheter ruptures.
211
 Intra-Aortic Balloon Counterpulsation
The word Counterpulsation stands for balloon inflation in
diastole and deflation in systole. Balloon inflation causes volume
shifting or displacement of blood in the whole aorta (proximal
and distal). which means an increase in coronary blood flow and
the vascular arterial system may occur. View Figure 10:2.

211
Primary Effect of IABP:
1- Increase myocardial oxygen supply: an increase in
diastolic pressure will lead to an increase in coronary
perfusion that can augment more oxygen supply to the
heart tissue.
2- Decrease myocardial oxygen demand: decreasing
systolic pressure (APSP) by decreased the end diastolic
pressure(Afterload),will reduce the work load of left
ventricle this means that the heart will exert less effort to
pump blood volume inside the aorta . (Sudden deflation
forming a space in the aorta that helps shifting the volume
from the left ventricle which decreasing the Afterload,
this will completely empty out the volume from the left
ventricle ( improving the cardiac output) and so will
decrease the wall tension inside the ventricle, and reduce
the load on the heart and so less oxygen is needed.
Afterload: Which is defined as the resistance in the arterial
circulation and the resultant left ventricular wall tension created
during systole. if the after load or blood pressure is elevated the
work load of the ventricle will increase in order to eject blood
against the greater resistance this increase in work load will
increase oxygen demand.

Secondary Effects of IABP:

1- Decrease heart rate.
2- Increase in cardiac output.
3- Decreasing systemic vascular resistant.
4- Decreasing the left ventricle end diastolic pressure.
5- Increasing mean arterial pressure, that will lead to an improvement
of the perfusion to all organ.
6- Reduces mitral valve regurgitation.
7- Increases LV ejection.
212
Effects on other systems:
Renal: increasing renal perfusion and urine output.
Neuro: increasing cerebral perfusion and enhancing the
neuro state.
Respiratory: increasing respiratory function by decreasing
the pulmonary capillary wedge pressure, and pulmonary
artery diastolic pressure.
Vascular: decreasing the systemic vascular resistance and
increasing the peripheral perfusion.

Indications for use of Intra-Aortic Balloon:

The aim of using IAB is to assist the circulatory
supporting of a failing left ventricle and here are the sum of
cases that requires the use of IABP.
1- Left Ventricular failure or Cardiogenic shock:
Left ventricle failure and cardiogenic shock are the most
common complications of acute myocardial infarction. In
the poor heart any decrease in arterial pressure can lead to
reduce the Oxygen supply to coronary arteries which leads
to an immediate injury to the functional myocardial
tissues, in these cases treatment is aiming to make a
balance between oxygen supply and demand and so reduce
the left ventricle workload, which is the main idea and goal
of using IABP.
2- Mechanical complications following MI (Acute MR, or
VSD): The myocardial infarction complications include
acute mitral regurgitation or a post infarction ventricular
septal defect. Mitral regurgitation (may be due to papillary
muscle dysfunction or ruptured chordae Tendineae).In
patients with mitral regurgitation the IABP reduces
afterload, increases forward flow, stroke volume and
213
 cardiac output. The resultant reduction in left ventricular
preload decreases pulmonary vascular congestion. in
patients with a post infarction ventricular septal defect
IABP decreases left ventricular afterload and increases
cardiac output while reducing the left-to-right shunt, right
ventricular pressure and central venous pressure.
3- Conjunction high risk patients who are to undergo
percutaneous transluminal coronary angioplasty
(PTCA) ,cardiac catheterization.
4- Acute myocardial infraction.
5- Septic Shock: IABP had important clinical value,
improved hemodynamics, and could be recommended as
an additional treatment option in patients with septic
shock in whom the effect of drug was poor.
6- Unstable angina: IABP use in patients with unstable
angina leads to an increase coronary blood flow and
reduction in myocardial oxygen demand to face of ongoing
ischemia
7- Operative (Pre, Intra, and Post): Prophylactic placement
of an IABP before anesthetic induction in patients who are
to undergo an open heart operation has been suggested,
that may be beneficial in patients who have a left
ventricular ejection fraction below 25% or a left
ventricular end-diastolic pressure greater than 20 mm Hg.
8- Bridging device to other mechanical assist device
therapy.
9- Support during transport.
10- Bridge to heart transplantation.
Contraindications for use of Intra-Aortic Balloon:
Absolute:
1- Aortic Valve insufficiency.
2- Dissecting aortic aneurysm.

214
Relative:

1- End-stage cardiomyopathy.
2- Severe atherosclerosis.
3- Abdominal aortic aneurysm.
4- Blood dyscrasias .
5- Thrombocytopenia.
6- Sepsis or infection.

Complications of Intra-Aortic Balloon

Limb ischemia .
Bleeding at the insertion site.
Infection complications and mostly at the insertion area.
Aortic dissection: which can happen from tearing the aorta
during the balloon insertion.
Thromboembolism.
False aneurysm.
Aortic Valve Rupture .
Reducing urine output related to positioning if it affect the
renal artery.
Incorrect timing causing increase afterload and stress of
left ventricle.
Balloon Catheter rupture and gas loss.
Hemolysis: due to mechanical damage to the red blood
cells.
Acute renal failure.
Thrombocytopenia: due to mechanical damage to platelets
or due to heparin administration.

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 Insertion of Intra-Aortic Balloon
Insertion must be performed under sterile technique,when
deciding to use IAB we must use a suitable size which is
provided by the manufacture, it depends on the height of the
patient to prevent occlusion of the renal arteries.

Table 44: Intra-Aortic Balloon Sizes

Balloon Balloon Membrane Dimensions Patient
Membrane Height
Volume(cc) Length(cm) Diameter(mm) cm
25 16.5 15 <152
MAQUT

34 22.1 15 152-162
40 25.8 15 162-183
30 23 14 147 162
ARROW

40 26 15 162 182
50 26 16 >182

The most common methods for IABP insertion are:

1- Percutaneous insertion: The technique starts by inserting a
puncture needle in the picked artery and then inserting a guide
wire then removing the needle and followed by a vessel dilator
then using a sheet or not but using a sheet is better in obese
patients, then inserting the balloon which must be deflated using
a syringe that comes with the insertion kit upon to the
manufacture instructions.
2- Femoral artery cut down insertion: This technique can be
used in patients where femoral pulse is not palpable or where
difficulty of insertion is anticipated as in patients suffering from
peripheral vascular disease(PVD) the common femoral artery is
dissected and the vascular fascia is opened. The common
femoral artery is isolated through a vertical groin incision. With
216
 a retractor the femoral artery can be dissected up to a length of 5
cm, and cotton tapes are placed proximally and distally of the
femoral artery. Then the insert starts. View Figure 10:3.

3- Intraoperatively insertion through Ascending Aorta

(Transthoracic Insertion): use if IAB insertion has been tried
and failed due to severe peripheral vascular disease (PVD), The
IAB catheter can be introduced down the aorta in operative
room situations. IAB catheter place antegrade down the
thoracic aorta. View Figure 10:4.

The position of the IABP is important and can be assured

first from the timing using the pressure wave and then by a chest
X-Ray to be sure where the tip of the balloon is positioned which
217
must be 2 centimeters below the take-off of the left subclavian
artery to prevent occlusion of the subclavian artery. On chest X-
rays, the tip should be visible between the 2nd and 3rd
intercostal space. View Figure 10:5.

Augmentation of Intra-Aortic Balloon

The balloon augmentation is the amount of helium in the
balloon catheter. It can be controlled via the balloon pump
console. we must be sure that the balloon is fully augmented
(inflated by a full amount of helium), this will assure that the
balloon is shifting the right amount of blood volume , and will
prevent formation of clots which may occurs by the sides of the
balloon if not fully inflated.

218
 Trigger of IAPB
The trigger is the IAB method to catch the beginning of the
cardiac cycle. Five methods can be used:
1. ECG: using R wave on the ECG to start pumping.
2. Pressure wave : the dicrotic notch in the arterial pressure
wave is used to initiate inflation.
3. Internal: The balloon inflates and deflates at a preset rate
regardless of the patients cardiac activity. This mode is
only to be used in situations where there is no ECG and no
cardiac output , such as cardiopulmonary bypass(Operator
mode). The balloon inflates and deflates by internal rate
with range between 40 and 120 beats/min.
4. Pacer V/AV: uses spikes of the ventricle that been
generated by pacing box.
5. Pacer A: uses the atrial pacing spike as the trigger signal.

Balloon Pressure Waveform

The Balloon Pressure Waveform (BPW) represents helium
movement between the console and the IAB catheter . View Figure 10:6.

211
 Balloon Pressure Waveform Height is a reflect of the pressure
in the aorta, therefore the plateau pressure on the BPW should be
within 25 mmHg (+/-) of the Diastolic Augmentation (PDP). View
Figure 10:7.

311
 Timing of IAPB
Timing: is relationship between the balloon inflation and
deflation ,and the heart systole and diastole.
Timing is the most important part to assure that the balloon
is not working against the heart which can lead to more
compromise to the heart. The timing is to have the right time of
inflation at the closure of the aortic valve and deflation at the
early systole. The inflation ratio refers to the number of balloon
inflations to the number of QRS complexes and can be set at 1:1,
1:2 or 1:3 .
During the timing the inflation ratio should be attempted at a
ratio of 1:2 to see the patient waveform (Unassisted IABP) vs the
augmented waveform (Assisted IABP) .
To understand IABP timing its necessary to review the
cardiac cycle . (see page 16 in chapter one).

311
Inflation: (filling balloon with helium) balloon inflation occurs
at the beginning of diastole, after aortic valve closure,
immediately after peak T wave in the ECG (during
isovolumetric relaxation), which can be seen in the pressure
waveform just prior to the dicrotic notch(lies at or slightly
above the dicrotic notch).

Deflation: (helium is transferred back from the balloon to

the tank) balloon deflation occurs just before the systole ,before
aortic valve open. In the ECG the deflation appear on peak of
R wave (during isovolumetric contraction). View Figure 10:8.

The effectiveness of IABP augmentation is reduced when

there is excessive tachycardia (>120 bpm) or cardiac arrhythmia.

312
 Proper Timing of IAPB
In proper timing waveform, balloon inflation occurs at just
prior to the dicrotic notch (inflation point lies at or slightly above
the dicrotic notch), this caused to exceeds Peak diastolic
pressure(PDP) above peak systolic pressure(PSP) .Deflation
occurs just prior the systole, this caused the balloon aortic end
diastolic pressure (BAEDP) is less than the patients aortic end
diastolic pressure(PAEDP) ,and the assisted peak systole
pressure (APSP) is less than unassisted peak systolic pressure
(PSP). Both inflation and deflation cause a sharp V shape.
View Figure 10:9.

Note: To see the balloon effects on arterial wave arterial clearly,

used a central balloon arterial line or a radial arterial line (not femoral).

313
 Common Timing Errors
Early inflation: Inflation point lies before dicrotic notch,
during systole, before the aortic valve is closed. It leads to
insufficient closure of aortic valve, and increases myocardial
stress and decreases cardiac output due to increasing in the
Afterload. View Figure 10:10.

Late inflation: happens when the balloon inflates lately after

the aortic valve closes. The dicrotic notch precedes the inflation
point, and the notch and the inflation point create a W shape.
This can lead to a reduction in peak systolic pressure and
coronary perfusion pressure. View Figure 10:11.

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 Early deflation: the balloon deflates early in diastole. This
error will lead to sub-optimal coronary perfusion, and will cause
a reduce on afterload reduction. Viewed as a sharp drop in the
waveform after diastolic augmentation. Assisted aortic end
diastolic pressure (BAEDP) can be equal to unassisted
(PAEDP).There may be little or no decrease in assisted systolic
pressure(ASP). There is an absence of the BAEDP V shape.

Late deflation: Late deflation has the same effects as early

inflation. Possibly the most dangerous of all timing errors. It
occurs when the balloon has been inflated too long. As a result,
the left ventricle has to eject blood against the resistance of the
inflated balloon. This increasing afterload, myocardial oxygen
consumption, cardiac workload, and preload. View Figure 10:13.

315
Common Timing Errors

316
 Abnormal Balloon Pressure Waveforms
Balloon pressure waveform is the source of information about
interaction of the IABP with the cardiovascular physiology of the
patient.
Low IABP balloon plateau pressure
The balloon plateau is a function of the helium pressure
inside the balloon and the pressure inside the aorta. Which relates
to the flexibility of the aortic walls ,and the systemic vascular
resistance as a whole .
Waveform Characteristics: Decreased height or amplitude ofz
the waveform.
Reasons:
The balloon is too small for the patient.
The patient is hypotensive.
Augmentation is too low.
Low systemic vascular resistance.
The balloon is too low in the aorta.
Physiologic Effects: Decreased diastolic augmentation (PDP),
and increased balloon aortic end-diastolic pressure (BAEDP) .

317
 High Balloon Plateau Pressure

High Balloon Plateau Pressure : Reflects an increase in

pressure on the balloon , or some resistance to gas flow.

Waveform Characteristics: Increased height or amplitude

of the waveform.

Reasons:
The balloon is too large for the patient.
The patient is hypertensive.
The balloon is positioned too high in the aorta.

Physiologic Effects: The balloon could rupture from too much

pressure. Or can lead to injury in the aorta .

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 Rounded Balloon Pressure Waveform

This may be caused by a kink in the catheter tubing or

improper IAB catheter position.

Waveform Characteristics: Rounded balloon pressure

waveform, loss of plateau resulting from a kink or obstruction of
shuttle gas.

Reasons:
The balloon catheter is kinked.
the IAB is too large for the aorta.
the IAB is partially wrapped.
water condensation in the external tubing.

Physiologic Effects: If the catheter is kinked, the balloon cannot

empty, and balloon deflation could be delayed, which results in a failure
to improve afterload, or an increase in afterload.

311
 Low Balloon Filling Pressure Baseline

Figure: Leak in the closed system causing the balloon

pressure waveform to fall below zero baseline.

Waveform Characteristics: Intra-Aortic Balloon filling

pressure is lower than the baseline.

Reasons:
Loose in connection.
Leak in the IAB catheter.
Water condensation in the external tubing.

Physiologic Effects: If the baseline filling pressure dives suddenly,

the cause could be either a disconnection of the helium pipe, or a
balloon rupture.

311
 High balloon filling pressure baseline

If the balloon filling pressure rises above the baseline

pressure , there is likely some mechanical fault with the circuit,
which limits the normal emptying of the balloon.

Waveform Characteristics: Intra-Aortic Balloon filling

pressure is higher than the baseline.

Reasons:
The balloon catheter is kinked .
Balloon is not emptying properly.
The system is over pressurized.

Physiologic Effects: Increased afterload, increased myocardial

oxygen demand, and eventually balloon maybe rupture.

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 Increased Duration of Plateau

Increased duration of plateau due to longer diastolic phase.

Reasons:
Bradycardia.

Decreased Duration of Plateau

Decreased duration of plateau due to shortened diastolic phase.

Reasons:
Tachycardia.

312
Causes of poor diastolic augmentation
1- The patients stroke volume is significantly higher or lower than the
balloon volume .
2- Balloon is positioned too low.
3- Severe cases of hypovolemia
4- Balloon is too small for the patients aorta
5- Low systemic vascular resistance ( SVR)
6- Improper timing (Late Inflation)
7- Catheter partially kinked, in sheath, not unwrapped view with
fluoroscopy .

Causes of poor afterload reduction

1- Balloon not large enough for the patients aorta or not filled to full
volume.
2- Compliant aorta.
3- Improper placement.
4- Partial obstruction of gas flow.

Nursing Care
Hourly hemodynamics recording and strict observation of the
circulation .
Hourly IABP ratio and level of augmentation.
making sure that the leg which has the balloon inserted is straight at
all times, avoid bending it.
Observing the insertion site make sure no evidence of infection and
bleeding.
Hourly urine output to assure the balloon does not effecting the
kidney .
Daily CXR to check the right position of IAB catheter .
Observe insertion site to make sure no infection or bleeding.
Observe and maintain normal coagulation and electrolyte balance
Observe the external tubing of the catheter for any kinks or blood
backflow
limb perfusion must be examined regularly and distal pulses checked
either by palpation or with a hand-held Doppler probe.

313
 Troubleshooting: (Reproduced from Linda Williams. Liverpool
Health Service .Intensive Care Unit. Self-Directed Learning Package: Intra-Aortic
Balloon Pumping).

The following are common problems that may occur when

using an IABP.
No trigger This means that the IABP has lost its tracing of
ECG or Pressure and is unable to time the inflation and deflation:
Action: To reconnect the ECG leads or pressure cable, or
change the ECG leads or tracing lead to obtain a better trace.

IAB Disconnected this means the IAB catheter extension

tubing has been disconnected and the pump will stop working.
Action: Reconnect the extension tubing, PRESS IAB Fill for 3
seconds till prompt is on the screen and the PRESS
Assist/Standby to start pumping.

Rapid Gas Loss - This will appear if there is a leak or hole in

the balloon or extension tubing. This means the balloon may be
ruptured, you will see flecks of blood in the tubing ( no gushing
blood, as blood is under pressure).
Action: If the balloon is losing its gas and filling is frequently
necessary, or blood flecks have been identified in the tubing,
then stop pumping and call the RMO. It will mean that the
catheter will need to removed and replaced. Check all
connections for any leaks or disconnections.

Check IAB Catheter this means that the IAB Catheter is

either kinked insitu or at the insertion site or it has not unwrapped
fully insitu.
Action: Examine the catheter and extension tubing for any
signs of kinking. Ensure that full augmentation is on, making
sure the balloon has the ability to expand. Examine the skin
insertion, as this is a common place for kinking. If problem
continues, contact RMO.

314
 Low Helium this means that the supply of helium is less than
24 fills.
Action: The helium cylinder needs replacing. Please ensure
that the O ring is not dislodged while changing the cylinder as
this ensures the seal.

Low Battery This means the battery has less than 30 minutes
of operating time.
Action: Ensure that the balloon pump is connected to the
mains power at all times, to recharge the battery.

IAB Failure This means that the IABP console fails to pump,
usually as a result of electrical malfunction or the presence of
blood in the condensers.
Action: Contact RMO. Disconnect patient from the IAB
console and obtain another IAB console (this should only to be
attempted if the balloon is not ruptured, as the same problem
will occur). Ensure that the machine is not labelled faulty.
Depending on the patients hemodynamic status, the IAB
catheter maybe removed.

Augmentation Below Limit Set - This means that the

augmented diastolic has fallen below the alarm set.
Action: Review the alarm set and consider lowering it in line
with the patients progress or if concerned with the drop, then
contact RMO.

In the event of a Code Blue - two methods of action

can be utilized:
1- Once CPR is started and a sufficient blood pressure is generated
with compressions, select the Pressure wave trigger and initiate
counterpulsation. This is the recommended option.
2- In the event that CPR cannot generate a consistent trigger, select
the Internal trigger. The balloon inflates and deflates by
internal rate(40-120 beats/min) regardless of the patients cardiac
activity.
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Weaning of IAPB:
Intra-Aortic Balloon generally improves the cardiac function
within 1-3 days at which time the IABP can be removed. Firstly,
the IABP augmentation can be reduced to 50% for 24 hours. The
inflation ratio is then progressively reduced from 1:1 to 1:2 for
another 24 hours and then to1:3 ,and observing the patient
hemodynamics before the balloon catheter is removed. The IABP
must be switched off and the catheter completely deflated just prior
to removal. Heparin should be discontinued at the start of IABP
weaning so that coagulation is normalized by the time the IABP
catheter is removed.

Removal of IAPB:
1. Carefully remove dressing from insertion site. Remove all
sutures and ties anchoring catheter to skin .
2. Switched off IABP and disconnect helium line from control
system .
3. When removing a balloon from a patient, remove balloon and
hemostasis sheath introducer as a unit.
(Do not remove the IABP through a sheath introducer. Once
unwrapped(After inflation), balloon profile will not allow passage
through the introducer and attempting removal in this manner may
result in arterial tearing, dissection, or balloon damage).
4. After remove the balloon, allow free flow of blood to flush
puncture site for several seconds.

5. Apply firm pressure to site for 30 minutes, or until hemostasis

has been achieved.
6. During and after removal, check distal pulses frequently and
assess for signs of complications.
In cases where a leak in the IAB is suspected, you must be very
careful during removal. If resistance is met during IAB catheter
removal, the percutaneous removal procedure should be stopped
and surgical removal via arteriotomy employed.

316
 Extracorporeal
Membrane Oxygenation
Extracorporeal membrane oxygenation (ECMO) is a type
of prolonged mechanical cardiopulmonary support, that is
employed as a temporary support to the management of live
threating of cardiac and/or pulmonary failure, or as a bridge for
further management (e.g. heart or lung transplantation), when no
other treatment option is likely to be successful.

The ECMO circuit differs from the traditional

cardiopulmonary bypass circuit, and it should be performed only
in centers with the appropriate equipment and expertise. The
ECMO circuit is a single closed system and is unable to tolerate
air in the venous line. ECMO circuits are smaller than CPB,
allowing for easier transportation of the patient. View Figure 10:22 .

317
 ECMO is used as a temporary support, usually for days or
weeks this period of therapy varied upon to patient case and
systems validity of use; which varied from six days up to 29 days
upon to manufacture advice or restrictions.
The circuit of ECMO consists of a membrane oxygenator
(flat silicone sheet) , pump(centrifugal or axial), flow console,
heat exchanger, and a close tubing system to prevent the contact
between air and blood. View Figure 10:23.

318
 ECMO provides a means of supporting blood gas exchange
using a membrane oxygenator. The blood is pumped through the
oxygenator, where gas exchange occurs, with the possibility to
control body temperature by cooling heating systems before
being returned to the patient, via either the venous or arterial
circulation.

Following a great and wide effort of many institutions for the

last forty years, technological advances in using ECMO , led to
reduce complications and technical defects , so the enhancements
and better understanding had contributed to spread the using of
ECMO as a life support and rescue technique (as the use with
H1N1 in 2009), those enhancements based on reducing heparin
use through using coating circuits ,reducing the priming volume
(especially in pediatric ) through using axial pumps, and short
less complicated circuits.

Once it has been decided that ECMO will be initiated, the

patient is anticoagulated with intravenous heparin and then the
cannulae are inserted. The utilizing equipment, including tubing,
cannula, oxygenator and blood pump, should be selected
optimally to enable rapid setup, successful cannulation and early
support, and to reduce the risk of device-related morbidity and
mortality. Monitoring of blood flow and blood pressure and
heparinization is a must during the use of all ECMO applications.
Typical ECMO circuits have heparin bonded tubing allowing for
lower levels of anticoagulation (ACT 180 220 s).

311
 Types of ECMO
The type of ECMO performed depends on patient condition,
which determine the mode of cannulation .

There are three types of ECMO cannulation strategies:

1- Veno-venous (V-V) ECMO.
2- Veno-arterial (V-A) ECMO.
3- Arterio-veno(AV) ECMO.

All those types provide respiratory support (gas exchange),

but only veno-arterial (V-A) ECMO provides hemodynamic
support (cardiac support) through augmented arterial circulatory
flow by the pump in the ECMO circuit .

1 Veno-venous(VV) ECMO:
VV ECMO provides respiratory support to patients with
respiratory dysfunction. Deoxygenated blood actively collected
(sucking being achieved by a mechanical pump) through a drainage
cannula from a point in the inferior vena cava just below the
diaphragm, passes through an oxygenator where carbon dioxide will
be removed and oxygen added , then it pumped back into venous
circulation through a reinfusion cannula.
Venous cannula are usually placed in the right common
femoral vein for drainage and right internal jugular vein for
infusion. The tip of the drainage cannula should be maintained
near the junction of the inferior vena cava and right atrium, while
the tip of the infusion cannula should be maintained near the
junction of the superior vena cava and right atrium. View Figure
10:24 .

321
 Alternatively, a double lumen cannula is available ,it is
inserted into the right internal jugular vein, draining blood from
the superior and inferior vena cava and returning it to the right
atrium. View Figure 10:25.

321
 The drainage and infusion ports have been engineered to
minimize re-circulation . View Figure 10:26 .

322
2-Veno-arterial(VA) ECMO; Also called Extracorporeal Life
Support (ELS):
VA ECMO provides both respiratory and hemodynamic
support to manage severe cardiac dysfunction with associated
impairment of blood gas exchange. Deoxygenated blood being
actively drained (sucking by a mechanical pump) through a
drainage cannula from a venous circulation, passes through an
oxygenator where carbon dioxide will be removed and oxygen
added, then it pumped back into arterial circulation through a
reinfusion cannula.
For VA ECMO, a venous cannula are usually placed in the
right common femoral vein for drainage and an arterial cannula is
usually placed into the right femoral artery for infusion. View Figure
10:27.

323
 Femoral access is preferred for VA ECMO because insertion
is relatively easy. Occasionally, the femoral vessels are
unsuitable for cannulation, such as the patients with severe
occlusive peripheral artery disease or prior femoral arterial
reconstruction. In such circumstances, the internal jugular vein
can be used for drainage, and the subclavian artery(or right
common carotid artery) for reinfusion. View Figure 10:28 .

For post cardiotomy VA ECMO, the cannulas employed for

CBP can be transferred from the heart lung machine to the
ECMO circuit, with blood drained from the right atrium and
reinfused into the ascending aorta .

Veno-venous(VV) and Veno-arterial(VA) ECMO are high-

flow ECMO with estimated percentage of about 7080% of
patient cardiac output in Veno-venous(VV) ECMO and an
estimated percentage of about 7595% of patient cardiac
output in Veno-arterial(VA) ECMO.

324
3 Arterio-veno(AV) ECMO (Pumpless Mode. low flow ECMO); Also
called Pump Less Extracorporeal Lung Assist (PECLA) or Interventional Lung
Assist (ILA) or Arterio-venous CO2 Removal (AVCO2R):

AV ECMO provides respiratory support to the patients with

severe acute respiratory distress syndrome who are at risk for life-
threatening hypoxemia and/or hypercapnia. Arterial-veno ECMO
works without a pump and using the patient pressure(arterio-venous
pressure gradient) to let the blood flow from the arterial side (Femoral
artery) to the venous side (Femoral vein) throw a membrane to ensure
a wash out for CO2. In AV ECMO systems patient hemodynamics
should be stable, with MAP > 60mmHg to allow blood flow and gas
exchange throw membrane oxygenator. View Figure 10:29 .

AV ECMO systems (low flow ECMO) remove CO2 from the

blood, but oxygenation is limited (partial oxygenation). Because it
receives only part of the cardiac output, thus just only a small part
(1015%) of cardiac output is treated, so a complete pulmonary
support is not possible, unlike VV and VA ECMO(High flow ECMO),
that achieve almost complete oxygenation as well as carbon dioxide
removal.
In patients with low cardiac output, the flow through membrane is
may be inadequate to wash out the CO2 .For these reasons, Veno-
venous CO2 Removal (VVCO2R) systems have been developed that
can use a Medium -flow pump (30% of cardiac output).
Monitoring blood flow and blood pressure is a must during the
use of all ECMO application.
325
 Indications and contra indications of ECMO
In general there is no restricted criteria or indications for ECMO use
and mostly it goes with different institutions policies and personal
experience, in this part we try to gather most conditions where the use of
ECMO is possible and may benefit and these indications and benefits are
able to be changed or modified as more technologies may appear in future
and more further studies can affect that too.

V-A and V-V ECMO Indications and contraindications

Indications of Pediatrics V-A and V-V ECMO:
There is no rigid indications in pediatrics, but as personal experience
the use of ECMO must be considered within first week in cases which we
use mechanical ventilator at high level of support, in new-born this can
occur in cases such as congenital lung disease, premature birth, and/or
congenital heart diseases, the use of ECMO can be as a bridge to surgery or
bridge to decision and/or as limited therapy, while the same can be targeted
in pediatrics more applications can be used in other cases like lung injury
due to accidents or pneumonia.

Contraindications of Pediatrics V-A and V-V ECMO:

1. Post-neurosurgical procedures or intracranial bleeding.
2. Increasing the risk of bleeding, post-surgery or trauma. Noticing that
ECMO can and had performed successfully in those cases, but as the
use of heparin either as heparinization tool or in coating circuits can
raise the bleeding possibility; the use of low ACT of (160-180) may be
more safe, with a continuous monitoring for platelets count and
bleeding factors.
3. When using ECMO age and weight must be considered to choose the
suitable set size, there is no weight limit, but in obese patients
cannulation may be difficult, and may necessitates the use of special
beds.
4. Severe neurologic compromise.
Relative contraindications of Pediatrics V-A & V-V ECMO:
1. Renal failure.
2. Primary pulmonary hypertension.
3. End stage hepatic failure.

326
Indications of Adults V-A and V-V ECMO:
1. Circulatory support through to recovery.
2. Failure to recover from cardiopulmonary bypass after cardiac
surgery.
3. Bridge to transplant, bridging strategies as bridge to bridge or bridge
to decision.
4. When a patient is listed for lung transplant and intubation is needed.
5. Circulatory support to permit further therapeutic and surgical
procedures.
6. Post perfusion cardiac failure.
7. Cardiopulmonary resuscitation.
8. Acute pulmonary embolism.
9. Cardiogenic shock.
10.Post-transplant acute rejection.
11.Hypoxic respiratory failure.
12.In cases of respiratory or cardiac collapse.
13.Patients on mechanical ventilation when CO2 retention occurs.
14.In severe air leak syndromes.

Contraindications of Adults V-A and V-V ECMO:

1. Sever Aortic valve insufficiency in V-A ECMO.
2. Vascular dissection and peripheral vascular diseases should be count
upon to cannulation site(e.g. Aortic dissection in V-A ECMO) .
3. Severe pulmonary hypertension (mPAP > 50mmHg) in V-V ECMO.
4. Severe right or left heart failure (EF< 25%) in V-V ECMO.

Relative Contraindications of Adults V-A and V-V ECMO:

Systemic anticoagulation therapy during the use of ECMO must be the
minimum comparing to patient situation and benefits of the use of ECMO, as
this support may represent a contraindication with bleeding or severe coagulation
disorders, and choices of priming as may be related to an allergy in certain cases.
1. Patients with Heparin allergy in heparin-albumin coating circuits, the
use of suitable coating for these patients is available.
2. Patients suffering from or with a history of type II heparin induced
thrombocytopenia (HIT) a special coating circuit is available for these
patients.

327
 Arterio-veno(AV) ECMO Indications
and Contraindications
Indications of AV ECMO:
This system removes CO2 from incoming blood and increases O2
levels while blood flows from arterial to venous side using patient
own pressure.
1. Severe acute lung failure due to acute respiratory distress
syndrome (ARDS).
2. Exacerbated COPD.
3. Bridge to lung transplantation.
4. Severe pneumonia.
5. Post-surgery for patients with difficulties to wean from
mechanical ventilator.
6. Post extubation when patients have difficulties in breathing.
7. Chest injury .
8. After thoracic surgical interventions .

Contraindications of AV ECMO:
1. Cardiovascular instability (hypotension, arrhythmias,
myocardial infarction).
2. Respiratory arrest.
3. Severe restriction of cardiac function (e.g. cardiogenic shock).
4. Heparin-induced thrombocytopenia(HIT).
5. Peripheral arterial occlusive vascular disease that would impair
perfusion of the lower limbs after cannulation.

328
 Priming of ECMO
Priming procedures have to come down easier and simple
since enhancements are being made to ECMO circuits and
oxygenators shape or bubble traps build in with membrane the
principle is easy since the circuit consists of tubes, a pump, a
membrane oxygenator, a machine, a cart (table) and a holder.

Priming Steps for ECMO Circuit:

1. Sterility is a must in all priming procedures or any
procedure attached to a patient.
2. Chose the correct type of ECMO coating, patients with
allergy needs special coating sets.
3. Due to differences in time period between different types
or manufactures pick a suitable type goes with the time
period of therapy upon to case, and targeted therapy
period.
4. Check machine and battery and this have different
procedure from one to another machine but will be well
known to users.
5. Connect Power.
6. Assemble ECMO circuit, that procedure is always easy
lines pump and an oxygenator.
7. Remove priming ports on access line.
8. Upon to hospital policy and manufacture direction of use
CO2 flush maybe required, attach CO2 into the priming
port from five to ten minutes.
9. Start filling priming bag with ringer lactate use a one liter
bag
10. When patient is on bypass then the ACT level will be over
400, if not to add 5000 units of heparin to the ringer lactate
bag.

321
11. Clamp both inlet and outlet of the membrane and start
filling the membrane, when you are sure no air is left in the
membrane, remove the inlet clamp and fill the line and
centrifugal coin, re clamp it and start filling the outlet line
to its end.
12. Attach both lines and start the pump raising the flow
gradually and reach at flow not less than five letters per
min keep the circuit running.
13. Close any opened caps as keeping it open will make air
bubbles enter the system and we need it later in case of re-
priming or de-airing in the existence of any bubble.
14. Some circuits are ready to use so just fill the bag with
brimming fluid and run the machine and bubble trap will
take over the whole procedure.
15. Choose cannulas to patient weight and site of cannulation,
same coating for the cannulas as the membrane oxygenator
is a must.
16. The machine is ready to use now we can transport it to the
bedside of the patient using holders provided.
17. Start gas flow to the oxygenator at a minimal rate of half a
liter.
18. Check heater cooler and start pump.
19. Clamp the inlet and outlet before attach to cannulas.
20. All connected and secure now release the out let clamp at a
flow of one liter and a half same time gradually release the
inlet clamp.
21. For data storing and comparing an arterial blood gas test
must be made before starting the circuit.
22. An ACT of 180 220 shall be preserved during the ECMO
circuit attachment to a patient, due to bleeding risk after
surgery it can kept at a lower range of 160 but more care
must be taken as this can form some dots of clotting in the
membrane.

331
 Cannulation of ECMO
The cannula size determines blood flow; that is why we shall
use the largest possible cannula that can achieve maximum flow
and so it become easier to achieve the targeted output .Cannula
size will depend on the vessel used and patient weight, sites are
variated but mostly the femoral artery and vein are used, in cases
post cardiac surgery we can use the same site of cannulation for
aortic and venous cannulas.
Table 45: ECMO Cannulation Site
Peripheral cannulation Central cannulation
Veno-Arterial ECMO
Femoral vein femoral artery Aorta-right atrium
Femoral vain-axillary artery Aorta-bicaval
Internal jugular vein -carotid artery
Internal jugular vein axillary artery

Veno-venous ECMO
Femero-femoral
Internal jugular femoral
Internal jugular (Dual lumen catheter)
Arterio-veno ECMO
Femoral artery femoral vein

Cannula sizes of ECMO:

1- Arterial cannula sizes: from 6 French up to 21 French.
2- Venous cannula sizes: from 8 French up to 29 French.
3- Double lumen venous cannula sizes : from 13 French up to 31 French.

331
 ECMO Cannulation techniques
* Cannulation must only done by a qualified certified persons.
Steps for cannulation:
1- Get your equipment, disinfectant, towels, and insertion kit
with cannulas.
2- Keep calm, quiet environment around you is better in any
surgical procedure.
3- Start preparing the patient using barriers if available, scrub
insertion area and apply drapes around it.
4- Heparinize the patient using 100 international unit / kg.
5- Assistant has to fill a bowel with normal saline and prepare
the insertion kit opened in sterile technique (insertion kits
comes ready with insertion needle, a syringe, guide wire, and a blade
for skin cutting or dilating around insertion area.) .
6- Use the needle provided with the insertion kit with the
syringe provided to locate the selected vessel.
7- Once the vessel is located; remove the syringe and admit
guide wire inside the needle.
8- Remove the needle and swap guide wire with a wet
compressor.
9- Insert dilators by guide wire from smaller size up to the
bigger provided size in order to reach the targeted size,
during this procedure keep swapping the guide wire after
each try with a wet compressor.
10- Insert cannula and remove the guide wire fill cannula with
patient blood (flush it).

332
Notice:
1- During initiating a vascular access, notice to be: efficient,
calm, and certain.
2- Use an ultrasound guidance if available, and notice that in
critically ill patients both venous and arterial blood could
look the same color so dont count on color or pressure
alone because it can mislead you during cannulation.
3- Double check that the wire is placed in the lumen of the
vessel.

Problems during the use of ECMO

1. Bleeding at cannulation site, in this case a compressor
must be put over the cannula at insertion site with some
pressure weight, and a check must be done surgically if
needed.
2. Clots in membrane due to low ACT, a daily check for
oxygenator must be done, and blood gas regularly test to
see effect of ECMO if it still works probably or not, and
watch pressure before and after membrane.
3. Air bubble entering the circuit, a new priming must be
done or an emergency replacement.

333
 Ventricular Assist Device
Ventricular assist device (VAD) is a mechanical pump
which is surgically implanted to one or both ventricles of the
heart, to augment or replace ventricular function . It is designed
to support heart function partially (either the right "RVAD" or
left "LVAD" ventricle) or completely(both at once "BiVAD" ) in
people who have heart Failure.
Ventricular assist device takes blood from a lower chamber
(ventricle) of the heart and helps pump it to the body, that
decrease the workload of the heart thereby reducing myocardial
oxygen demand , while maintaining adequate systemic perfusion.
The increase in systemic perfusion improves myocardial oxygen
supply. That reduction in myocardial oxygen demand and
improvement in myocardial oxygen supply helps in ventricular
recovery.
Heart failure continues to be an ever-growing public health
concern facing our world today. Many peoples are being
diagnosed with heart failure, with many new cases diagnosed
each year, heart failure is one of the top leading causes of death
in the world. Cardiac transplantation has been considered as the
best treatment for end-stage heart failure. However, limitation of
donor organs have relegated transplantation as a viable option for
only very small percentage of this population. Thus, ventricular
assist device (VAD) is offered for patients with chronic or acute
end-stage heart failure with the expectation that ventricular
recovery will occur , in order to provide the patient with the
opportunity for ventricular recovery .
VAD is implanted either as a bridge to transplantation or as a
bridge to recovery or as an alternative to heart
transplantation(called destination therapy, a patient who will
never get a heart transplant). This device mostly implants in the
left ventricle which is called left ventricular assist devices
(LVAD) ,it helps the left ventricle pump blood to the aorta. But
334
when pulmonary arterial resistance is high, right ventricular
assist device (RVAD) may become necessary to helps the right
ventricle pump blood to the pulmonary artery. Both an LVAD
and RVAD sometimes are used if both ventricles don't work well
enough to meet the needs of the body , they may be called a
biventricular assist device (BiVAD). View Figure 10:30 .

335
 Components of VAD
The basic parts of a ventricular assist device include an
inflow tube that carries blood out of heart through a pump ,
outflow tube that returns blood to either the ascending aorta or
the main pulmonary artery, driveline(A cord passes through the
skin and holds the control and power wires , that connects the
device to an external portable driver), and portable driver
consisting of a control unit (that monitors the VAD functions)
and a power source ( that may be worn around the waist, carried
in a shoulder bag, or contained within a small bedside monitor).
View Figure 10:31 .

336
 VAD Pump Types
The pumps used in ventricular assist device can be divided
into two main categories: pulsatile and non-pulsatile(continuous)
flow pumps.
Pulsatile Flow Pumps:
Most pulsatile devices are extracorporeal and consist of a
blood chamber, air chamber with compressor-operated
membrane, and valves. Blood enters via an inflow cannula and
fills the blood chamber, then the pneumatic pump ejects the
blood into systemic circulation via the outflow cannula by
pumped air with high pressure into an air chamber to collapse the
blood chamber . View Figure 10:32 .

Pulsatile devices sequentially fill and empty mostly during

native cardiac systole, as the ventricle empties into the blood
chamber. Pulsatile Flow Pumps mimic the natural beating action
of the heart. Therefore, the patients will have palpable pulses and
a measurable blood pressure . Pulsatile devices generate pulse not
synchronous with native electrical systole. Indeed, even if the
patient has a dysrhythmia, such as ventricular fibrillation or a
systole on cardiac monitor, the patient will still have a palpable
337
pulse because of on assist pump ejection, although it is likely to
be at a reduced rate, as the pump may fill more slowly because of
reduced delivery from the right side of the heart.
Pulsatile pumps are preload dependent, and the rate of
ejection depends on the speed at which the blood chamber can
fill and empty and it can be set at a fixed rate or can
automatically adjust. Pump output is dependent upon blood sac
volume, preload, afterload, and pump rate.
Continuous Flow Pumps (Non-Pulsatile):
These pumps are driven by either axial flow or centrifugal
pumps. In the axial flow pumps, the spinning rotors(impellers)
are more cylindrical with blades that are helical, forcing blood
along the axis of the rotor. whereas in centrifugal pumps, the
rotors are shaped to accelerate the blood circumferentially and
thereby move it toward the outer rim of the pump. Potential
advantages of axial flow pumps include: smaller size, easier
surgical implantation, quieter vibration-free operation, enhanced
patient comfort, and extended durability. View Figure 10:33 .

Continuous flow devices transmit flow throughout the

cardiac cycle during both systole and diastole, but the greatest
augmentation is during diastole when there is usually no native
flow. Most blood flows into the pump during systole, as this is
when the left ventricle ejects blood into the pump and the
pressure difference between the ventricle and aorta is smallest.
338
Compared with patients who do not have VADs, recipients of
continuous flow devices have lower systolic pressures and
elevated diastolic pressures, resulting in significantly diminished
pulse pressures.

The higher the pump speed is set, the less pulsatility exists,
as the pump effectively empties the left ventricle before it can
generate much systolic pressure. If the speed is set too high or
delivery of blood to the left ventricle is reduced, the pump may
decompress the left ventricle too much and effectively collapse
the left ventricle walls together, which is known as a suction
event. Conditions that may result in reduced blood delivery to the
left ventricle and therefore to the pump include those that result
in either absolute or relative hypovolemia: bleeding, right
ventricular dysfunction, pulmonary hypertension, cardiac
dysrhythmias, pericardial tamponade, systemic vasodilation, and
hypotension. All ventricular assist devices are basically preload
dependent, ECG independent, afterload sensitive, and
anticoagulated.

331
 Clinical indications for VADs

Ventricular assist devices can be used for a wide spectrum

based on the therapeutic goals of circulatory support as well as
the duration of treatment. They can be used for short term as well
long term duration. The indications are typically divided into 3
categories: bridge to recovery, bridge to transplantation, and
destination therapy.
Bridge to recovery
VADs as a Bridge to recovery are used for patients who
need only temporary support for days to weeks in anticipation of
recovery of ventricular function followed by weaning and
removal of the device. This includes patients with acute
inflammatory cardiomyopathies, acute cardiogenic or post-
cardiotomy shock and myocardial infarction.

Bridge to transplantation
Bridge-to-transplantation is the strategy in which VADs
are used for improving ventricular function and peripheral
perfusion in patients awaiting cardiac transplantation. Several
studies have demonstrated that VADs ensure sustained
improvement in hemodynamic status and quality of life in
patients awaiting cardiac transplantation. LVADs are decreases
the filling pressures and increases cardiac output by taking over
the work of the left ventricle, this leads to decrease pulmonary
vascular resistance and a reduction in afterload for the right
ventricle. Additionally, the increase in cardiac output provides
additional preload for the right ventricle, which further enhances
its function. As a result, the presence of the LVAD can partially
or totally reverse functional impairment of these organs and all
organ systems benefit from the increase in perfusion, allowing
patients to stabilize or improve as they wait for a heart transplant.
341
Destination therapy
Destination therapy is the strategy in which VAD are used as
an alternative to cardiac transplant to support the patients for
their entire life. It involves the largest population of the patients
with end stage heart failure who are unable to receive cardiac
transplantation.

Complications of VAD
The most common complications of VADs implanted
include: Hemorrhage including pericardial tamponade, right
ventricular failure, sepsis, device thrombosis, cable malfunction,
mechanical device failure, neurologic dysfunction, and infection.

341
 Table 46 : Most Common Types of VAD and Its Characteristics

Devices Manufacturer Type of Configuration Placement Duration

Flow of Use

EXCOR BiVAD Long-

Berlin Heart Pulsatile Extracorporeal
VAD RVAD/LVAD term
BiVAD Short-
BVS 5000 Abiomed Pulsatile Extracorporeal
RVAD/LVAD term
Long-
Novacor World Heart Pulsatile LVAD Implantable
term
Long-
HeatMate II Thoratec Axial LVAD Implantable
term
Long-
HeartMate III Thoratec Axial LVAD Implantable
term
Long-
DuraHeart II Terumo Centrifugal LVAD Implantable
term
Long-
DeBakey MicroMed Axial LVAD Implantable
term
Long-
LionHeart Arrow Pulsatile LVAD Implantable
term
BiVAD Short-
*Impella Abiomed Axial Implantable
RVAD/LVAD term
Long-
Incor Berlin Heart Axial LVAD Implantable
term
BiVAD Long-
HeartWare HeartWare Centrifugal Implantable
RVAD/LVAD term
Long-
HeartMate X Thoratec Axial RVAD/BiVAD Implantable
term
Long-
HeartAssist5 ReliantHeart Axial LVAD Implantable
term
Long-
Jarvik 2000 Jarvik Heart Axial LVAD Implantable
term
BiVAD Short-
CentriMag Levitronix Centrifugal Extracorporeal
RVAD/LVAD term
BiVAD Short-
PediVAS Levitronix Centrifugal Extracorporeal
RVAD/LVAD term
Total Artificial Long-
CardioWest SynCardia Pulsatile Implantable
Heart term
Total Artificial Long-
Jarvik 7 Jarvik Heart Pulsatile Implantable
Heart term
Total Artificial Long-
BiVACOR BiVACOR centrifugal Implantable
Heart term

* Impella Devices: are minimally invasive catheter pumps that can support
the heart with up to 5.0 liters blood per minute. The pumps can be
implanted percutaneous via a cut-down.
342
343
 Abbreviations
ACT: Activated Clotting Time .
ADH: Anti-diuretic Hormone .
AV ECMO: Arterio-veno Extracorporeal Membrane Oxygenation .
AVI: Aortic Valve Insufficiency .
AICD: Automatic Implantable Cardiac Defibrillator .
aO2 content: arterial oxygen content .
Ao Dissection: Aortic Dissection .
APSP: Assisted Peak Systole Pressure .
AR: Aortic Regurgitation .
ARDS : Adult Respiratory Distress Syndrome .
AS: Aortic Valve Stenosis .
ASA: Atrial Septal Aneurysm .
ASD: Atrial Septal Defect .
AT: Anti-thrombin .
ATP: Adenosine Triphosphate .
AV: Atrioventricular .
AVCO2R: Arterio-veno CO2 Removal .
AVD: Assisted Venous Drainage .
BDG: Bidirectional Glenn Operation .
BiVAD: Biventricular Assist Device .
BUN: Blood Urea Nitrogen Mg/Dl .
BP: Blood Pressure .
BVH: Biventricular Hypertrophy .
CAD: Coronary Artery Disease .
CPB: cardiopulmonary bypass .
CBF: Cerebral Blood Flow .
CHD: Congenital Heart Disease (or Defect) .
CHF: Congestive Heart Failure .
CI: cardiac index .
CL-: Chloride Mmol/L .
CM: Cardiomyopathy .
CMR: Cerebral Metabolic Rate .
344
CMRO2: Cerebral Metabolic Rate for Oxygen .
CO: Cardiac Output (Lpm) .
COA: Coarctation of the Aorta .
COPD: Chronic Obstructive Pulmonary Disease .
CPP: Cerebral Perfusion Pressure .
CSF: Cerebrospinal Fluid .
CVA: Cerebral Vascular Accident .
CVP: Central Venous Pressure (mmHg) .
DA: Diastolic Augmentation .
DHCA: Deep Hypothermic Circulatory Arrest .
DN: Dicrotic Notch .
DORV: Double Outlet Right Ventricle .
ECC: Extracorporeal Circulation .
ECD: Endocardial Cushion Defect .
ECG: Electrocardiograph or Electrocardiographic .
Echo: Echocardiography or Echocardiographic .
ECLS: Extracorporeal Life Support .
ECMO: Extra-Corporeal Membrane Oxygenation .
ELS: Emergency Life Support System .
ELSO : Extracorporeal Life Support Organization .
HCO3: Bicarbonate mmol/l .
EF: Ejection Fraction .
FiO2: Inspiratory O2 concentration .
GLU: Glucose mg/dl .
GME: Gaseous Microemboli .
HB: Hemoglobin content gm/dl .
HCM: Hypertrophic Cardiomyopathy .
Hct: Hematocrit value % .
HITI: Heparin Induced Thrombocytopenia type I .
HITII: Heparin Induced Thrombocytopenia type II .
HOCM: Hypertrophic Obstructive Cardiomyopathy .
HLHS: Hypoplastic Left Heart Syndrome .
HTN: Hypertension .
IABP: Intra-Aortic Balloon Pump .
345
ICD: Implantable Cardioverter-Defibrillator .
ICP: Intracranial Pressure .
ILA: Interventional Lung Assist .
IP: Inflation Point .
IVC: Inferior Vena Cava .
K+: Potassium mmol/l .
LA: Left Atrium Or Left Atrial .
LAD: Left Axis Deviation .
LAE: Left Atrial Enlargement .
LBBB: Left Bundle Branch Block .
LMWH: Low Molecular Weight Heparin .
LPA: Left Pulmonary Artery .
LV: Left Ventricle or Ventricular .
LVAD: Left Ventricular Assist Devices .
LVEF: Left Ventricular Ejection Fraction Written as Percent .
LVH: Left Ventricular Hypertrophy .
LVOT: Left Ventricular Outflow Tract .
MAP: Mean Arterial Blood Pressure .
MAPCA: Multiple Aortopulmonary Collateral Arteries .
MI Dates: Myocardial Infarction and Dates of Each .
MPA: Main Pulmonary Artery .
MR: Mitral Valve Regurgitation .
MUF: Modified Ultrafiltration .
MS: Mitral Valve Stenosis .
MVP: Mitral Valve Prolapse .
Na+: Sodium Mmol/L .
PA: Pulmonary Artery .
PaCO2: Partial Carbon Dioxide Tension .
PAEDP: Patients Aortic End Diastolic Pressure .
PaO2: Partial Oxygen Tension .
PAPVC: Partial Anomalous Pulmonary Venous Connection .
PAPVR: Partial Anomalous Pulmonary Venous Return .
PBF: Pulmonary Blood Flow .
PCO2: Carbon Dioxide Partial Pressure .
346
PDA: Patent Ductus Arteriosus .
PDP: Peak Diastolic Pressure .
PECLA: Pump Less Extracorporeal Lung Assist .
PEEP: Positive End Expiratory Pressure .
PFO: Patent Foramen Ovale .
PI: Pulmonary Valve Insufficiency .
PLAT: Platelets X 1000 /mm3 .
PO2: Oxygen Partial Pressure .
PPHN: Persistent Pulmonary Hypertension of Newborn .
PR: Pulmonary Valve Regurgitation .
PS: Pulmonary Valve Stenosis .
PSP: Peak Systolic Pressure .
PT: Prothrombin Time in Second .
PTT: Partial Thromboplastin Time in Second .
PVC: Premature Ventricular Contraction .
PvO2: partial pressure of venous oxygen.
PVOD: Peripheral Vascular Obstructive Disease .
PVOD: Pulmonary Vascular Obstructive Disease .
PVR: Pulmonary Vascular Resistance .
Q: blood flow .
RA: Right Atrium or Atrial .
RAD: Right Axis Deviation .
RAE: Right Atrial Enlargement .
RBBB: Right Bundle Branch Block .
RHD: Rheumatic Heart Disease .
RPA: Right Pulmonary Artery .
RV: Right Ventricle or Ventricular .
RVAD: Right Ventricular Assist Devices .
RVEF: Right Ventricular Ejection Fraction Written as Percent .
RVH: Right Ventricular Hypertrophy .
RVOT: Right Ventricular Outflow Tract .
S1: First Heart Sound .
S2: Second Heart Sound .
S3: Third Heart Sound .
347
S4: Fourth Heart Sound .
SBE: Subacute Bacterial Endocarditis .
SEM: Systolic Ejection Murmur .
SIRS: Systemic Inflammatory Response Syndrome .
SOB: Short of Breath .
S/P: Status Post .
SV: Stroke Volume .
SVC: Superior Vena Cava
SVR: systemic vascular resistance .
SVT: Supraventricular Tachycardia .
TAPVC: Total Anomalous Pulmonary Venous Connection
TAPVR: Total Anomalous Pulmonary Venous Return .
TCA: Total Circulatory Arrest .
TCPC: Total Cava Pulmonary Connection .
TEE: Trans Esophageal Echocardiography .
TGA: Transposition of The Great Arteries .
TIA: Transient Ischemic Attack .
TOF: Tetralogy of Fallot
TPR: Total Peripheral Resistance .
TR: Tricuspid Valve Regurgitation .
UFH: Unfractionated Heparin .
UMB ART: Umbilical Arterial Pressure (mmHg) .
URI: Upper Respiratory Infection .
VAD: Ventricular Assist Device.
VA ECMO: Veno-arterial Extracorporeal Membrane Oxygenation.
VAVD: Vacuum Assisted Venous Drainage .
VO2 content: Venous oxygen content.
VSD: Ventricular Septal Defect .
VVCO2R: Veno-venous CO2 Removal .
VV ECMO: Veno-venous Extracorporeal Membrane Oxygenation.
WPW: Wolff-Parkinson-White .

348
341
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