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Cardiopulmonary Bypass: Principles and Practice

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CHAPTER 3: BLOOD PUMPS

EIKI TAYAMA STEVEN A. RASKIN YUKIHIKO NOS Quick Links to Sections in this Chapter ROLLER PUMPS CENTRIFUGAL PUMPS PULSATILE PUMPS NONOCCLUSIVE ROLLER PUMP KEY POINTS References E. Tayama: Department of Surgery, Kurume University School of Medicine, Kurume City, 830 Japan. S. A. Raskin Department of Surgery, Baylor College of Medicine, Houston, TX 77030. Y. Nos Department of Surgery, Baylor College of Medicine, Houston, TX 77030.

Various types of blood pumps are available for cardiopulmonary bypass (CPB). The ideal pump for CPB should have the following characteristics:

y y y

It must be able to pump blood at a flow rate of 7 L/min against a pressure of 500 mm Hg. The pumping motion should not damage the cellular or acellular components of blood. All parts in contact with the bloodstream should have a smooth continuous surface with no dead space to cause stagnation or turbulence, should be disposable, and should not contaminate the permanent parts of the pump.

Calibration of pump flow should be exact and reproducible so that blood flow can be accurately monitored.

In the event of a power failure, the pump should be manually operable.

Four types of blood pumps are currently available for CPB: roller, centrifugal, pulsatile, and nonocclusive roller.

ROLLER PUMPS

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The roller pump is one type of positive displacement pump. It has been the most commonly used type for CPB for the past five decades, although its popularity has recently fallen as a result of improvements in systems using centrifugal pumps.

History
The roller pump was first patented (patent 12,753) in 1855 by Porter and Bradley (1). Potential applications listed in this patent included use as a scavenger for cleaning of privies, as a stomach pump, and as an apparatus for injection. In 1887, Allen patented a pump designed for blood transfusion. In 1934, DeBakey et al. (2) made a modification to the Porter-Bradley infusion pump to prevent creepage of the latex rubber tubing during blood transfusion (patent 2,018,998) (Fig. 3.1). This was accomplished by placing a flange on the outer circumference of the tubing that was then clamped into the pump housing. In 1959, Melrose proposed a more advanced design, in which the roller ran along the tubing held in place by a grooved backplate. The tube guides prevented lateral motion of the tubing during operation.

FIG 3.1. Original DeBakey roller pump. Note dual rollers and knob for View Figure rotating roller assembly. This pump required specially edged tubing (D, right) for securing it between plates in the roller mechanism. A: Plane view of instrument. B: Side view.C: Cross-section. D: Cross-section of tube. (Reprinted from DeBakey ME. A simple continuous-flow blood transfusion instrument. New Orleans Med Surg J 1934;87:387, with permission.)

Structures
Roller pumps contain a length of tubing located inside a curved raceway. This raceway is placed at the travel perimeter of rollers mounted on the ends of rotating arms. These arms are arranged in such a manner that one roller is compressing the tubing at all times. By compressing a segment of the blood-filled resilient tubing, blood is pushed ahead of the moving roller, thereby producing continuous blood flow (Fig. 3.2). The output of the rotary pump is determined by the revolutions per minute (rpm) of the pump and the volume displaced with each revolution. The volume depends on the size of tubing and length of the track.

FIG 3.2. Conventional heartlung machine, with five roller pump modules. Typically, one roller pump is used to pump blood into the systemic circulation (usually through a membrane oxygenator) and other separate roller pumps are used for delivery of View Figure cardioplegic solutions, suction from the surgical field, and/or left ventricular venting. (Model HL-20, courtesy Jostra USA, Austin, TX.)

According to the number of rollers, roller pumps are classified as single, double, and multiple roller pumps. The single-roller pump consists of a circular raceway in which a 360-degree loop of tubing is inserted. Single-roller pumps were used for CPB in the 1950s and early 1960s because they produced more pulsatility than conventional double-roller pumps. The double-roller pump, which has been the most commonly used pump for CPB, consists of a 210-degree semicircular backing plate and two rollers with the rotating arms set 180 degrees apart (Fig. 3.3). When one roller ends its occlusive phase, the other has already begun its occlusive phase. Because one of the two rollers is always compressing the tubing, the double-roller pump generates a relatively nonpulsatile flow. Although the multiple-roller pump has been proposed for extracorporeal blood handling, it is not clinically available because it causes more hemolysis.

FIG 3.3. Double-roller pump module, showing a large knob (right) that controls revolutions per minute, which are displayed digitally on the front of the console. (Courtesy Jostra USA, Austin, TX.) View Figure

Tubing
There are three basic materials currently used for tubing: silicone rubber, latex rubber, and polyvinyl chloride (PVC). These tubing materials have all been used in CPB. PVC is most widely used for roller pumps because of its durability and acceptable hemolysis rates (3,4). Latex rubber generates more hemolysis than PVC, whereas silicone rubber produces less hemolysis when the pump is completely occluded (4). PVC tubing stiffens during hypothermic CPB and tends to induce spallation, which refers to the release of plastic microparticles from the inner wall of tubing as a result of roller pump compression (36). Silicone rubber tubing releases more particles than PVC (7).

Occlusiveness
Occlusion can be adjusted by either increasing or decreasing the compression of the tubing by the rollers. This compression appears to be critical. Excessive compression induces hemolysis and tubing wear, whereas too little occlusion may also aggravate hemolysis but, more important, compromises forward output (3). The exact output of the roller pump may vary during CPB, and it is difficult to determine the exact flow rate due to occlusion variance throughout the bypass (8). At nonocclusive settings, roller pump output can be sharply decreased, resulting in hypoperfusion (3,9). Although controversial, it is generally believed that adjusting tubing compression to be barely nonocclusive results in the least hemolysis (3,4). Rawn et al. (10) found no difference in hemolysis between a roller pump with a standard set occlusion and a centrifugal pump at a 4.5-L/min blood flow rate with an afterload of 250 mm Hg. When the occlusion is opened such that pumping at 5 rpm against occluded tubing maintains a pressure of 150 to 225 mm Hg, the roller pump induces less hemolysis than a centrifugal pump. The occlusion is set by holding the outflow line vertically so the top of the

fluid is about 60 to 75 cm above the pump and then gradually decreasing occlusiveness until the fluid level falls at a rate between 1 and 12 cm/min (3,11).

Complications
Some problems arising from roller pumps include malocclusion (over- or underocclusion), miscalibration, fracture of the tubing, "runaway" pumping (12), loss of power, spallation, and the capacity to pump grossly visible air (3). If the outflow becomes occluded, pressure in the line will progressively increase until either the tubing or connectors disconnect or break. If the inflow becomes limited, the roller pumps will develop a high negative pressure producing microscopic air bubbles ("cavitation"). Roller pumps may also develop pinhole leaks, which may lead to pushing microscopic air bubbles toward the patient (3). Stoney et al. (13) attributed 92 deaths and 61 permanent injuries to arterial line embolism from roller pumps between 1972 and 1977.

CENTRIFUGAL PUMPS
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Centrifugal pumps for CPB have been commercially available since 1976 (14). At many institutions, the centrifugal pump has replaced roller pumps for routine CPB for cardiovascular surgery. They are also used for mechanical circulatory support, including ventricular assistance, percutaneous cardiopulmonary support, and extracorporeal membrane oxygenation (1517).

Characteristics
The basic design of a centrifugal pump consists of an impeller arranged with either vanes or a nest of smooth plastic cones inside a plastic housing. The impeller couples magnetically with an electric motor either directly or through a tether. The magnet inside the disposable pump head spins in conjunction with another magnet spinning in the drive console. This magnetic coupling means that the speed (rpm) of the driver magnet inside the console equals the rotational speed of the pump. When the impeller rotates rapidly, it generates a pressure differential causing blood flow (i.e., a negative pressure at the inlet port of the pump pulling blood into the pump housing and a positive pressure at the outlet port expelling blood). Excessive rotational speed can cause decoupling, in which the impellers or cones cannot spin as fast as the driver motor (3). The tether is driven either by a turning shaft or by an electrically powered remote magnet. Figure 3.4 shows the relationship between the pressure differential created (pressure head) and flow rate of a centrifugal pump. In this figure, N1, N2, N3, and N4 are the arbitrary rotational pump speeds. The dotted lines indicate the pressure-flow characteristics of an ideal centrifugal pump, which can generate constant pressure regardless of flow rate, with negligible loss of pressure head inside the pump. In actual centrifugal pumps, however, the pressure-flow relationship deviates from ideal as a result of pressure head loss in the pump head and in the inflow and outflow cannulas. As flow rate increases, pressure head loss increases. This relationship can be modeled as follows:

where N is the pump rotational speed, Q is the flow rate, and K1 and K2 are constants appropriate to each particular pump. The pressure head for an ideal pump can be described as P = K1 x N2, in which the generated pressure head would be proportional to the square of the impeller rotational speed. This equation allows prediction of the pump head pressure drop from the pump rotational speed and flow.

FIG 3.4. Typical relationship between total pressure head and flow rate for a centrifugal pump. N
1

through N
1

each represent a constant level of revolutions per

4

minute (rpm), with N View Figure

representing the highest rpm value and N

the lowest.

Comparison with roller pumps

Table 3.1 compares advantages and disadvantages of roller pumps and centrifugal pumps. Centrifugal pumps are disposable and add approximately $150 (U.S.) or more to the cost of an individual procedure as compared with the cost of performing the procedure with a roller pump, which requires only a piece of tubing integrated into the extracorporeal circuit/oxygenator disposable kit. The most commonly used extracorporeal perfusion blood pumps (roller and centrifugal) have adverse pressure regulation properties that can lead to fatal accidents. With the standard roller pump, the most recognized hazard is overpressurization and circuit rupture if the tubing downstream from the pump (outlet side) is accidentally kinked or clamped. Additionally, if the tubing upstream from the pump (inlet side) is accidentally kinked or clamped, the roller pump will generate dangerously low negative pressures that could result in blood cavitation, hemolysis, and suction of room air through loose stopcocks or tubing connectors. Positive and negative pressure control in occlusive roller pumps is typically accomplished with additional electronic equipment such as pressure control modules or with a mechanical bladder that shuts off the pump if dangerous pressures are generated (18). Centrifugal pumps have become popular mainly because unlike roller pumps, they cannot overpressurize. Similar to roller pumps, however, centrifugal pumps can generate very large negative pressures if the tubing upstream from the pump is restricted. Also, because they are nonocclusive, retrograde flow can occur with loss or severe reduction in forward flow from any cause. If the arterial inflow line occludes, the centrifugal pump will not generate excessive pressure (peaking at about 700 to 900 mm Hg). Likewise, if the inflow line occludes, they will not generate high negative pressures (reaching about 400 to 500 mm Hg), thereby reducing the risk of cavitation and microembolus as compared with roller pumps (3,18). Both centrifugal and roller pumps are capable of actively sucking blood from an open venous reservoir and thus are susceptible to emptying the reservoir and pumping air to the patient. It has been claimed that centrifugal pumps hinder passage of air pulled in from an empty reservoir (1820). This property should not be perceived as a safety feature or a method of preventing the pumping of air,

however, because it has been well established that centrifugal pumps do pump air to various degrees (21). By design, centrifugal pumps are nonocclusive, preload dependent, and afterload dependent. When the impeller is not spinning, fluid can flow through the pump head in either direction (nonocclusive). When the pump stops running for any reason, such as decoupling, blood can flow retrograde through the pump head unless the arterial line is clamped. This backflow can cause exsanguination of the patient or aspiration of air from around the purse-string sutures securing the arterial cannula (22). Therefore, whenever the centrifugal pump is not running, the CPB arterial line must be clamped. Centrifugal pumps generate increased flow when either the preload increases or the afterload decreases (preload dependent and afterload dependent). When using a roller pump, a sharp decrease in systemic vascular resistance must be accompanied by an increase in the frequency of roller head rotation if one wishes to maintain a constant arterial pressure. With centrifugal pumps, the flow rate automatically increases without a change in rotational speed when systemic vascular resistance decreases (23). Varying sensitivities to preload and afterload preclude determination of pump flow directly from rotational speed; therefore, a flow meter must be incorporated into the arterial outflow. The flow probe should be located downstream of any purge or recirculation line in the circuit to accurately measure blood flow delivered to the patient. Electromagnetic and ultrasonic flow meters are used clinically for centrifugal pumps. Electromagnetic flow probes depend on the fact that blood flowing through an electromagnetic alters a magnetic field in a manner that can be measured continuously ("right-hand rule"). Electromagnetic flow probes require blood-contacting electrodes and are designed as connectors, which possess the disadvantages inherent to transition gaps. In contrast, ultrasonic flow probes do not contact the blood but instead wrap around the tubing. The frequency shift in the Doppler signal is related to the velocity of blood flow through the tube. Standard ultrasonic flow devices measure the maximal blood velocity and calculate the flow based on the assumption of a simple parabolic (laminar) velocity distribution (actual flow profiles are not parabolic), whereas electromagnetic devices assess mean velocity distribution. Additionally, the Doppler signal becomes very noisy at low velocities, so most ultrasonic flow probes do not measure low flows accurately (24). A reduced risk of passing clinically significant amounts of macroscopic air into and through the arterial line to the patient has been a reported advantage of the centrifugal pump over the roller pump. If more than 32 to 52 mL of air is introduced into the circuit, the centrifugal pump becomes deprimed and stops pumping (3). Also, the centrifugal pump transmits fewer microscopic air bubbles, probably from a combination of shear force and positive pressure generation within the pump head (21). DeBois et al. (25) prospectively compared centrifugal pumps and roller pumps in 200 patients undergoing elective coronary bypass grafting. The study demonstrated a significant reduction in length of hospital stay, a reduced 24-hour postoperative weight gain, and a net reduction in hospital cost in the centrifugal group. Clearly, both roller pumps and centrifugal pumps have advantages and disadvantages. Although clinicians may believe strongly that one or the other should be used

preferentially for cardiac surgery requiring CPB, there are insufficient clinical outcome studies available as yet to reach a conclusion about the desirability of one pump type over the other for routine cases. For more prolonged applications of CPB or circulatory support, the theoretic advantages of centrifugal pumps over roller pumps become more compelling.

Complications
Centrifugal pumps are generally safe, and the overwhelming majority of cardiac operations are completed without incident. Although these pumps will not pass large quantities of gas, centrifugal pumps are nonocclusive, and therefore retrograde flow can occur whenever the pump malfunctions, stops, or when the pump slows enough so that the pressure produced is less than that needed to maintain forward flow (26). Retrograde flow can create a hemodynamic siphon that can exsanguinate the patient and can draw air into the arterial line at the cannulation site (22). In vitro studies demonstrated that retrograde flow could commence 540 ms after power to the pump is shut off. The reverse flow occurs even though the rotor is still spinning and can rise up to 2.5 L/min after another 470 ms (26). The only way to prevent retrograde flow is for the perfusionist to clamp the arterial line when the pump slows or stops. To sustain a pressure adequate to maintain forward flow, the perfusionist should partially occlude the arterial inflow line when low flows are requested, as when the patient is weaned from CPB. However, incidents have occurred where the perfusionist has forgotten to clamp the arterial line. Human errors are cited as the factor believed responsible for 73.3% of perfusion accidents, compared with 19.5% for device malfunctions or failures (27). The U.S. Food and Drug Administration records about centrifugal pump malfunctions from November 1991 through October 1993 revealed that 68 pump malfunctions, 22 electrical burning smells, and 3 speed surges were reported out of 350,000 open heart operations using centrifugal pumps (failure rate, 1/3,763 cases) (28). To prevent retrograde flow associated with pump malfunction, low flow, and human errors, incorporating a oneway valve into the arterial line has been recommended (26). Although clinically available, such valves have not gained widespread use, and such issues as blood trauma, possible stasis and cavitation, the potential for valve failure, and cost effectiveness need to have further evaluation.

Specific clinically available centrifugal pumps BioMedicus pump

In 1976, the first centrifugal pump was used for CPB (Medtronic BioMedicus, Inc., Eden Prairie, MN). This pump was first marketed in 1978 as an alternative to the roller pumps (14). The pump head is acrylic, with inlet and outlet ports oriented at right angles to each other, and its priming volume is 80 mL (Fig.3.5A). Pump flow rate is measured by an electromagnetic flowmeter in the CPB arterial line, which is not susceptible to inaccuracy from turbulence, hematocrit levels, temperature, and other factors. The rotor consists of a stack of parallel cones driven by magnetic coupling to the external console (Fig. 3.5B). Figure 3.6 demonstrates the pressure-flow relationship for this pump. Rotation of the parallel cones induces centrifugal force and radial flow to the blood that passes between the cones (constrained force-vortex principle). Shear rates between the cones were estimated at 100 to 400 s
1

at flow rates of 400 to 2,000 mL/min (29). In contrast, the shear rates between the rotating outer

cone and the stationary conical pump housing vary, with a peak value of about 2.57 s1/rpm, being a function of the pump rotational speed rather than of the flow rate.

FIG 3.5. A: Cross-sectional schematic of the BioMedicus Bio-Pump centrifugal pump. (Courtesy Medtronic BioMedicus, Inc., Eden Prairie, MN) B: Console that drives and regulates the BioMedicus centrifugal pump. Part of the pump is seen mounted at the View Figure top rear. Digital displays and the knob controlling the revolutions per minute are located on the console's top panel and other controls are on its front. This console is reasonably representative of those used for the centrifugal pumps of other manufacturers. (Courtesy Medtronic BioMedicus, Inc., Eden Prairie, MN.)

View Figure

FIG 3.6. Hydraulic performance curves for the Bio-Pump. (Courtesy Medtronic BioMedicus, Inc., Eden Prairie, MN.)

View Figure

Some investigators have reported less hemolysis with the BioMedicus pump than with roller pumps (30,31), whereas others have reported the contrary (14,32) or no difference between the two (33,34).In vitro studies demonstrated that the BioMedicus pump induces less hemolysis at pressureto-flow ratios below 1 mm Hg/mL/min, whereas a roller pump produces less hemolysis at the ratios above 1 mm Hg/mL/min (29). Because pressure-to-flow ratios during CPB nearly always remain well below that threshold, this distinction may have no clinical importance. Wheeldon et al. (32) compared the BioMedicus pump with the Stockert roller pump in a prospective randomized study of 16 patients undergoing coronary artery bypass grafting and found the BioMedicus pump to be associated with greater preservation of platelet numbers, less complement activation, and less microbubble transmission. In patients with CPB times over 2 hours and in those over the age of 70, perfusion with the BioMedicus pump resulted in higher postperfusion platelet counts (35). Parault and Conrad (36) found less blood damage with the BioMedicus pump than with roller pumps when CPB time exceeded 90 min. Platelet counts, plasma hemoglobin, altered with the BioMedicus pump. BioMedicus pumps are thought to prevent the transmission of macroscopic and microscopic air and clots better than roller pumps and other impeller pumps. These pumps are also less likely to churn air -thromboglobulin, and D-dimer were significantly less

into the blood than roller pumps (14). Clots and air bubbles tend to remain in the BioMedicus pump, whereas other types of impellers may permit them to pass into the patient.

Delphin pump
The Sarns 3M Delphin centrifugal pump (Sarns 3M, Ann Arbor, MI) has a vaned magnetically coupled impeller within an acrylic housing (Fig. 3.7). As with the BioMedicus pump, the inflow and outflow ports are oriented at right angles to each other, and the priming volume is 40 mL. Blood flow is measured by an ultrasonic flowmeter along the outlet tubing and is proportional to the rotational speed. In vitrocomparison of the Delphin and BioMedicus pumps demonstrated that mean plasma hemoglobin levels were significantly higher with the Delphin pump at 2, 4, and 6 L/min of flow (36). Platelet counts were significantly lower with the BioMedicus pump at 2 and 4 L/min of flow, with no difference found at 6 L/min of flow.

FIG 3.7. Cross-sectional schematic of the Delphin centrifugal pump. 1: roller shaft; 2:sealing part; 3: vane; 4: absence of stagnant flow area behind the impeller; 5:nonsealed ball bearing; 6: magnet. (Courtesy Sarns 3M, Ann Arbor, MI.) View Figure

Life stream pump

The Life Stream centrifugal pump (St. Jude Medical Inc., Chelmsford, MA) was introduced clinically in 1988. The impeller is composed of curved vanes to minimize eddies and cavitation and to optimize overall flow patterns (Fig. 3.8). The shaft, seal, and bearings have been modified to reduce the risk of blood contact and potential pump failure. The shaft is magnetically coupled to the driver console with integrated battery backup. An electromagnetic flowmeter measures blood flow. The pressureflow relationships at various rpm are shown in Figure 3.9. An in vitro comparative study demonstrated similar rates of hemolysis between the BioMedicus and Life Stream pumps after 4 hours of pumping, both of which were significantly lower than that found with the Delphin pump (37). The Life Stream and Delphin pump heads were almost identical in the rotational speeds required to achieve a given flow rate and were 20% to 30% lower than those required for the same flows with the BioMedicus pump (Fig. 3.10) (37).

FIG 3.8. Cross-sectional schematic of the Life Stream centrifugal pump. 1: blood path;2: curved vane; 3: thin metal drive plates; 4: back side of vane; 5 and 6: quad-ring double seal; 7: sleeve bearing; 8: stainless steel shaft; 9: thrust View Figure bearing. (Courtesy St. Jude Medical Inc., Chelmsford, MA.)

FIG 3.9. Hydraulic performance curves for the Life Stream (Isoflow) pump. (Courtesy St. Jude Medical Inc., Chelmsford, MA.)

View Figure

FIG 3.10. Comparison of the performance curves among the Delphin pump, Life Stream pump, and BioMedicus pump. (Reproduced from Noon GP, Sekela ME, Glueck J, et al. Comparison of Delphin and BioMedicus pumps. ASAIO Trans 1990;36:M616 View Figure M619, with permission.)

Capiox pump
The Capiox centrifugal pump (Terumo Corp., Tokyo, Japan) consists of a rotor with a unique straightpath design to reduce pump rotational speed without decreasing hydraulic efficiency (3840) (Fig.3.11). The straight-path design with a constant cross-sectional area minimizes the change of blood flow velocity and direction. Figure 3.12 demonstrates the pump's performance, which is noteworthy for less afterload sensitivity at higher flows when compared with other centrifugal pumps. The small priming volume of approximately 46 mL may reduce stagnant flow within the rotor. In vitro studies revealed that the time required for blood temperature to increase from 37 to 42C after outlet clamping was four times longer in the Capiox pump than in the Delphin pump and two times longer than in BioMedicus pump (40). These studies also demonstrated that no cavitation was observed when 0.1 mL of air was introduced into the Capiox pump under a negative pressure of 200 mm Hg. In vitro tests revealed that the Capiox pump caused less hemolysis than a roller pump (35) and the BioMedicus pump (4143). A clinical study demonstrated less hemolysis, less platelet depletion, and lower (39). -thromboglobulin levels in the Capiox group than in the roller pump group

FIG 3.11. Cross-sectional schematic of the Capiox centrifugal pump. (Courtesy Terumo Corp., Tokyo, Japan.)

View Figure

FIG 3.12. Hydraulic performance curves of the Capiox pump. (Courtesy Terumo Corp., Tokyo, Japan.)

View Figure

Nikkiso pump
The Nikkiso centrifugal pump (Nikkiso, Inc., Tokyo, Japan, and HIMEX Production, Inc., Houston, TX) is the smallest commercially available centrifugal pump (4446). It has an impeller diameter of 50 mm, a priming volume of 25 mL, an outer diameter of 66 mm, a height of 58 mm, and a weight of 145 g. Figure3.13 shows the design of the pump, which is made of polycarbonate, with a V-shape ring seal that separates the pump housing and actuator chamber. This seal, which is made of fluororubber, suppresses heat generation and prevents blood leakage (44). Six washout holes are incorporated into the impeller to generate blood flow from the back to the front surface of the impeller. These holes prevent thrombus formation in the areas behind the impeller and around the sealing part. Figure 3.14shows the hydraulic characteristics of the Nikkiso pump. Although very small, the pump can generate 6 L/min of flow against a total pressure head of 400 mm Hg at a rotational speed of 3,500 rpm.

FIG 3.13. Cross-sectional schematic of the Nikkiso centrifugal pump. (Courtesy Nikisso, Inc., Tokyo, Japan, and HIMEX Production, Inc., Houston, TX.)

View Figure

FIG 3.14. Hydraulic performance curves for the Nikkiso pump. (Courtesy Nikisso, Inc., Tokyo, Japanand HIMEX Production, Inc., Houston, TX.)

View Figure

Because the Nikkiso pump has been marketed primarily in Japan, Japanese investigators (4752) reported most of the clinical experience. Lower plasma free hemoglobin concentrations accompany perfusion with the Nikkiso pump than with the roller pump or the BioMedicus pump (4851). It was also reported that the parameters of platelet destruction and activation (e.g., platelet factor 4 and thromboglobulin) increased less with the Nikkiso pump than with other pumps (52,53). -

PULSATILE PUMPS
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Even conventional roller pumps produce some pulsatile flow (54). However, one of the methods to generate more pulsatile blood flow during CPB is to use intraaortic balloon pumping (55). A dramatic increase in postoperative ejection fraction was observed in the pulsatile perfusion group with intraaortic balloon pumping (56). Other devices and techniques used to achieve pulsatile flow during CPB are discussed more thoroughly in Chapter 10.

NONOCCLUSIVE ROLLER PUMP

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The Metaplus pump (Baxter Healthcare Corporation, Cardiovascular Group, Irvine, CA; originally Affinity model 2000, Avecor Cardiovascular, Inc., Minneapolis, MN) is a new type of blood pump that appears to incorporate some advantages of a centrifugal pump while minimizing some disadvantages of a conventional roller pump (18). This pump will not drain the venous reservoir, will not create negative pressure and cavitation, will not overpressurize, and will not allow retrograde flow. Forward fluid flow is accomplished by a passive-filling tapered pumping chamber fabricated of two sheets of flat polyurethane tubing bonded at the edges (58). This pump chamber segment is stretched under tension over three rollers. Unlike a conventional roller pump, the Metaplus pump is considered nonocclusive because there is no backing plate against which the tubing can be compressed with rollers. The rollers are mounted on a rotor that spins to impart a peristaltic action on the fluid within the pump chamber. The priming volume is 120 mL (Fig. 3.15).

FIG 3.15. Schematic drawing of nonocclusive roller pump. A: Operating principle of the triple-roller pump and pumping chamber. Polyurethane pumping chamber is stretched over the rollers, and roller rotation is counterclockwise. EView Figure E: Cross-sectional view of pumping chamber distended when blood is supplied at a pressure above ambient. B: Pumping chamber inlet collapsed when blood is not supplied at a pressure above ambient. F-F: Cross-sectional view of the collapsed pumping chamber. (Reprinted from Montoya JP, Merz SI, Bartlett RH. Significant safety advantages gained with an improved pressure-regulated blood pump.. J Extra-Corp Technol 1996;28:7273, with permission.)

The pumping chamber shape is normally flat from being stretched over the rollers when the pump is not rotating. However, with any hydrostatic filling pressure above ambient levels, the pumping chamber expands and fills with fluid. Forward flow occurs with roller rotation, as it does with a conventional roller pump. If the tubing upstream from the pump (pump inlet) is kinked or clamped, the pump chamber will collapse into its natural flat shape. When this occurs, forward flow ceases. The pump chamber lacks the tendency to return to an inflated condition because it has no "memory."

Thus, the pump cannot generate negative pressures and will not tend to damage blood and tissue or to suck air through loose tubing connectors upstream. The pump chamber fills passively as a function of the height of the fluid column within the reservoir. Reservoir volume changes will have little effect on pump flow rate until the volume drops to a minimum level. Once that level is reached, there is insufficient hydrostatic pressure to fill the pump chamber and flow ceases, demonstrating the preload sensitivity of the pump. When venous return is reestablished, blood flow resumes gradually. As a result, air is not entrained nor does a potentially cavitating vortex form at the outlet of the CPB reservoir. As stated earlier, the potential for retrograde flow is a key safety concern with nonocclusive pumps. With the Metaplus pump, the pump chamber flattens and becomes occlusive as it wraps around the individual rollers to prevent retrograde flow from the patient. The pump is also afterload sensitive, because the pressure it generates is limited. If the arterial line occludes, the flat segment of the pump chamber becomes distended and the pump then becomes nonocclusive. This occurs at pressures lower than those required to induce failure of tubing connections. Because the system is both preload and afterload sensitive, a noninvasive electronic flow probe must be used to accurately measure blood flow, and a separate modular pump console must be used to control the pump (Fig. 3.16).

FIG 3.16. Metaplus pump rotor and motor assembly (right) and membrane oxygenator (left). Pump position is fixed in relationship to the hard-shell venous reservoir to supply the inlet of the pump. Note requirement for large-bore, semirigid, View Figure U-shaped tubing connecting the outlet of the venous reservoir to the inlet of the pump. (Courtesy Baxter Healthcare, Cardiovascular Group, Irvine, CA.)

In vitro testing (57) has confirmed the inability of the pump to empty a CPB reservoir when the height of the pump inlet is placed slightly above the reservoir outlet, decreased microbubble emission when compared with conventional roller or centrifugal pumps, and lower or comparable hemolysis rates. Additional in vitro studies by Jaggy et al. (59) and a clinical study by Crockett et al. (60) further characterized the performance of the pump under varying preload and afterload conditions typically encountered during CPB. The cost of disposables for this new pump system are intermediate between those of the less expensive roller pump and the more expensive centrifugal pump.

KEY POINTS
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The ideal pump for CPB would be able to deliver physiologic blood flows against high resistance without damaging blood, should provide flows that are exact and easily monitored, should create no turbulence or stagnation, and should be manually operable in the event of a power failure.

y y

The two pumps used most commonly for CPB are roller pumps and centrifugal pumps. Roller pumps have the advantages of simplicity, low cost, ease and reliability of flow calculation, and the ability to pump against high resistance without reducing flow. Disadvantages include the need to assess occlusiveness, spallation of the inner tubing surface that potentially produces particulate arterial emboli, capability for pumping large volumes of air, and ability to create large positive and negative pressures.

Compared with roller pumps, centrifugal pumps offer the advantages of lesser air pumping capabilities, lesser abilities to create large positive and negative pressures, less blood trauma, and virtually no spallation. Disadvantages include higher cost, the lack of occlusiveness (creating the possibility of accidental patient exsanguination), and afterload-dependent flow requiring constant flow measurement.

Four commercially available centrifugal pumps demonstrate some differences in hydraulic performance, afterload sensitivity, priming volumes, ability to transmit air, and possibly blood trauma.

A nonocclusive roller pump has been recently introduced. This pump appears to be incapable of generating dangerously high positive or negative pressures or of permitting retrograde flow. This pump is undergoing clinical evaluations to establish its appropriate clinical applications.

In the setting of short-term CPB for cardiac surgery, it remains uncertain whether the selection of a roller pump over a centrifugal pump or of any specific centrifugal pump over another has clinical significance.

References
Back to Quick Links 1. Cooley DA. Development of the roller pump for use in the cardiopulmonary bypass circuit. Texas Heart Inst J 1987;14:113118. 2. DeBakey ME. A simple continuous-flow blood transfusion instrument. New Orleans Med Surg J1934;87:386389. 3. Hessel EA. Cardiopulmonary bypass circuitry and cannulation techniques. In: Gravlee GP, Davis RF, Utley JR , eds. Cardiopulmonary bypass, principles and practice . Baltimore: Williams & Wilkins, 1993:5592. 4. Bernstein EF, Gleason LR. Factors influencing hemolysis with roller pumps. Surgery 1967;61:432442.

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