PERFUSION LINE

CONTINUING EDUCATION IN EXTRACORPOREAL TECHNOLOGY

Literature Abstracts
VACUUM ASSISTED VENOUS DRAINAGE
1: Zhonghua Zheng Xing Wai Ke Za Zhi. 2006 Nov;22 (6):465-7. Effect of vacuum assisted closure on collagenase activity in human chronic wound. Shi B, Zhang P, Li WZ, Chen SZ, Li JQ. Department of Plastics and Aesthetic, the 406th Hospital, PLA , Dalian, 116041, China. OBJECTIVE: To study the variations of collagenase activity in exudates of human chronic wound before and after treatment of VAC so as to partly disclose the mechanisms of VAC in promoting chronic wound healing. METHODS: The exudates of acute wounds (postoperative breast cancer) were postoperatively collected at day 1, 2, 3, and in 6 chronic wounds (4 cases of venous ulcer, 2 cases of pressure sore) the exudates were also collected before and 2, 4, 6 days after the treatment with VAC. The type-III collagen degradation from the exudates was checked with zymography timepoint. The types of the collagenase in exudates were evaluated by using doxycycline inhibition. RESULTS: Drainage fluids from acute wound might degrade type-III collagen partly with no changes at day 1, 2, 3. There were high collagenase activities in chronic wound exudates. Exudates from patients before treatment with VAC can degrade type-III collagen completely. But collagenase activities became less and less after VAC. Doxycyline inhibition tests indicated that it can't inhibit the activity of collagenase at 100 micromol/L concentration, until it reached 600 micromol/L. CONCLUSIONS: Collagenase activity is elevated in chronic wounds. VAC may be lower the collagenase activity, prevent collagen from degrading abundantly and promote wound healing. Collagenase is mainly MMP-1 type (fibroblast-type) in chronic wound exudates. 2: Anesteziol Reanimatol. 2006 May-Jun;(3):38-41. Evaluation of the safety of auxiliary venous drainage in

FEB. 2007

the surgical treatment of patients with acquired cardiac diseases. Akimov IV, Bakanov AIu. The present study has comparatively analyzed two procedures of auxiliary venous drainage: 1) that by means of vacuum (VaVD), 2) that using an additional roller pump (ARP) and the conventional extracorporeal circulation (EC) with gravitation venous drainage (GVD). The material for the study was the number of microembolic signals (MES) in the middle cerebral artery bed and neurological disorders in patients operated on for cardiac valvular diseases. According to the venous drainage procedure, the patients (n = 90) were divided into 3 groups: 1) those (n = 30) with traditional GVD; 2) those (n = 30) with VaVD; 3) those (n = 30) with ARP. The study revealed the impact of different venous drainage procedures on the number of MES and the patients' neurological status. 3: Ann Thorac Surg. 2006 Mar;81(3):1146-7. Total cavopulmonary connection: open anastomosis of an extracardiac conduit with vacuum-assisted venous drainage. Aeba R, Yozu R, Morita M, Matayoshi T. Division of Cardiovascular Surgery, Keio University, Tokyo, Japan. Insertion of a tube conduit for total cavopulmonary connection is sometimes technically demanding due to the crumpled stump of the inferior vena cava caused by a tourniquet of the inferior vena cava near the division line. Herein we describe an alternative in which the anastomosis is completed during removal of the tourniquet with the application of vacuum-assisted venous drainage. This new technique may alleviate, if not completely eliminate, a concern associated with total cavopulmonary connection with extracardiac conduit in

Literature Abstracts
small patients. 4: ASAIO J. 2005 Sep-Oct;51(5):644-8. Vacuum-assisted venous drainage during fetal cardiopulmonary bypass. Lubbers WC, Baker RS, Sedgwick JA, Lam CT, Schenbeck JL, McNamara JL, Ferguson RE, Lombardi J, Gardner A, Clark KE, Eghtesady P. Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, USA. Fetal bypass presents several perfusion challenges, including the need for high arterial flow rates using flexible arterial and small venous cannulae. We hypothesized that vacuum-assisted venous drainage (VAVD) would improve drainage and allow perfusion at higher flow rates which are thought to prevent placental dysfunction induced by fetal bypass. We conducted bypass for 60 minutes in 14 fetal lambs (90-105 days gestation; approximately 1-1.5 kg) using a roller pump and various angled venous cannulae (8-12 Fr). VAVD at -20 mm Hg or -40 mm Hg was compared with gravity drainage. Average flow using gravity drainage was 139 ml/ kg/min; after VAVD, we achieved average flows of 285 ml/kg/min (range, 109-481 ml/kg/min). VAVD at -40 mm Hg caused right atrial trauma in four fetuses; no injury was seen at -20 mm Hg. Venous air entrainment during repair of the injuries did not result in any apparent air embolism. Spontaneous pulmonary hemorrhage occurred in two fetuses at the highest flows (> or = 400 ml/kg/min). In all but one case, termination of bypass was followed by placental dysfunction within 120 minutes. VAVD can be safely applied during fetal bypass provided pressures are kept < or = -20 mm Hg. However, the achieved higher flow rates do not prevent postbypass placental dysfunction and may indeed be detrimental to the fetus. 5: J Artif Organs. 2005;8(2):91-4. Venous drainage method for cardiopulmonary bypass in single-access minimally invasive cardiac surgery: siphon and vacuum-assisted drainage. Murai N, Cho M, Okada S, Chiba T, Saito M, Shioguchi S, Gon S, Hata I, Yamauchi N, Imazeki T. Department of Cardiovascular Surgery, Misatokennwa Hospital, Misato, Saitama 341-8555, Japan. nomurai@agate.plala.or.jp Vacuum-assisted venous drainage (VAVD) can facilitate venous drainage in single-access minimally invasive

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cardiac surgery (SAMICS). We retrospectively examined the use of VAVD in SAMICS in our hospital for this report. VAVD has been performed according to a VAVD protocol since 2000. Data from the 110 patients who underwent SAMICS in our institute from January 2000 to June 2002 were reviewed retrospectively. The total negative pressure was maintained at no greater than 90 mmHg. Indications for use of VAVD (protocol) were: insufficient venous return by siphon drainage alone, persistent elevation of the central venous pressure (CVP), and, insufficient venous drainage in the operative field. Of 110 patients, 97 (88.2%) underwent VAVD. The body surface area was significantly smaller in the group that did not require VAVD (the non-VAVD group) than in the group that did (VAVD group) (VAVD group versus non-VAVD group: 1.586 +/- 0.175 versus 1.408 +/- 0.153 m(2), P < 0.001). Other factors such as cardiopulmonary bypass time, aortic cross-clamp time, postoperative maximum lactate dehydrogenase, postoperative maximum creatinine, postoperative maximum blood urea nitrogen were similar in the two groups. VAVD is necessary in SAMICS except for small patients. A VAVD total negative pressure of -90 mmHg did not hinder operative procedures or cause clinical problems. 6: Am J Clin Dermatol. 2005;6(3):185-94. Mechanisms and clinical applications of the vacuumassisted closure (VAC) Device: a review. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. Georgetown University Medical Center, Washington, USA. The use of sub-atmospheric pressure dressings, available commercially as the vacuum-assisted closure (VAC) device, has been shown to be an effective way to accelerate healing of various wounds. The optimal subatmospheric pressure for wound healing appears to be approximately 125 mm Hg utilizing an alternating pressure cycle of 5 minutes of suction followed by 2 minutes off suction. Animal studies have demonstrated that this technique optimizes blood flow, decreases local tissue edema, and removes excessive fluid from the wound bed. These physiologic changes facilitate the removal of bacteria from the wound. Additionally, the cyclical application of sub-atmospheric pressure alters the cytoskeleton of the cells in the wound bed, triggering a cascade of intracellular signals that increases the rate of cell division and subsequent formation of granulation tissue. The combination of these mechanisms makes the VAC device an extremely versatile tool in the armamentarium of wound healing. This is evident in the VAC device's wide range of clinical applications, including treatment of infected surgical wounds, traumatic wounds, pressure ulcers, wounds with exposed bone and hardware, diabetic foot ulcers, and venous stasis ulcers. VAC has also proven useful in reconstruction of

Literature Abstracts
wounds by allowing elective planning of the definitive reconstructive surgery without jeopardizing the wound or outcome. Furthermore, VAC has significantly increased the skin graft success rate when used as a bolster over the freshly skin-grafted wound. VAC is generally well tolerated and, with few contraindications or complications, is fast becoming a mainstay of current wound care. 7: J Extra Corpor Technol. 2004 Dec;36(4):336-42. The effectiveness of low-prime cardiopulmonary bypass circuits at removing gaseous emboli. Norman MJ, Sistino JJ, Acsell JR. Cardiovascular Perfusion Program, Medical University of South Carolina, Charleston, South Carolina 29425, USA. During extracorporeal circulation, the patient's blood is siphoned into the extracorporeal circuit (ECC) by gravity or may be assisted kinetically or by vacuum. In all instances, negative pressure is generated in the venous line, which can cause entrainment of air into the ECC at the cannulation site. The typical ECC uses a venous reservoir, membrane oxygenator, and arterial line filter, which together aid in removal of air that has entered the venous line and minimize the transmission of gaseous microemboli to the patient. Recently, several manufacturers have introduced low prime ECCs with component configurations that differ from conventional ECCs, including the omission of a venous reservoir. These configuration changes may change the ability of the circuit to handle air and therefore their ability to minimize gaseous microemboli. The purpose of this study was to test the ability of new low prime ECCs to remove air introduced into the venous line and minimize gaseous microemboli from entering the patient's circulation. Using a model of CPB, air was introduced into the venous line of a low prime ECC and a conventional CPB circuit. The detection of the gaseous microemboli produced was monitored distal to the oxygenator by an ultrasonic emboli detector to determine if venous air was able to traverse the ECC at varying rates of air introduction and blood flow. Data was collected using data acquisition software loaded on a personal computer. Gaseous microemboli levels detected in the arterial line of the low prime ECC were 8 to 10 times higher than the microemboli levels detected in the conventional ECC at all blood flow rates. Every effort should be made to minimize and prevent air from being entrained in the venous line of a low prime CPB circuit to minimize the risk of arterial gaseous microemboli generation. 8: Ann Thorac Surg. 2004 Dec;78(6):2057-62. Hemodynamic changes during posterior vessel off-

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pump coronary artery bypass: comparison between deep pericardial sutures and vacuum-assisted apical suction device. Chang WI, Kim KB, Kim JH, Ham BM, Kim YL. Department of Thoracic and Cardiovascular Surgery, Seoul, South Korea. BACKGROUND: Displacement of the heart to expose posterior vessels during off-pump coronary artery bypass may cause hemodynamic derangement. The aims of this study were (1) to elucidate the hemodynamic changes during off-pump coronary artery bypass for the obtuse marginal branch (OM) of the left circumflex artery; and (2) to compare the hemodynamic changes caused by a deep pericardial suture technique with those caused by a vacuum-assisted apical suction device for displacement of the heart. METHODS: Hemodynamic changes during posterior vessel off-pump coronary artery bypass were studied in a prospective randomized manner. A deep pericardial suture technique (group 1, n = 10) or a vacuum-assisted apical suction device (group 2, n = 10) was used to facilitate the exposure of the OM. Hemodynamic variables such as cardiac index, stroke volume index (SVI), mean arterial pressure, mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, heart rate, systemic vascular resistance, pulmonary vascular resistance, left ventricular stroke work index, and right ventricular stroke work index were monitored during off-pump coronary artery bypass. Hemodynamic data were obtained before revascularization of the left anterior descending coronary artery at a baseline (T0), 3 minutes after heart displacement for revascularization of OM (T1), 3 minutes after the beginning of OM grafting (T2), and 3 minutes after the completion of OM grafting and heart repositioning (T3). RESULTS: There were no significant differences in the baseline hemodynamic variables (T0) between the two groups. In group 1, SVI, cardiac index, left ventricular stroke work index, and right ventricular stroke work index decreased significantly, and central venous pressure and pulmonary capillary wedge pressure increased significantly, during displacement of the heart (T1, p < 0.05). In group 2, SVI decreased significantly, and central venous pressure, pulmonary capillary wedge pressure, and mean pulmonary artery pressure increased significantly during displacement of the heart (T1, p < 0.05). The percent changes of cardiac index, SVI, and right ventricular stroke work index during OM grafting (T2) in comparison with baseline values (T0) were significantly larger in group 1 than in group 2 (cardiac index, 73% +/- 12% versus 90% +/- 11%; SVI, 69% +/12% versus 86% +/- 8%; right ventricular stroke work index, 30% +/- 17% versus 71% +/- 25%, in groups 1 versus 2, respectively; p < 0.05). CONCLUSIONS: Displacement of the heart using either a deep pericardial suture technique or a vacuumassisted apical suction device caused a significant de-

Literature Abstracts
crease in SVI. The hemodynamic changes during OM grafting were smaller when using a vacuum-assisted apical suction device. 9: Ann Thorac Cardiovasc Surg. 2004 Aug;10(4):24951. Resection of giant right atrial lymphoma using vacuumassisted cardiopulmonary bypass without snaring the inferior vena cava. Shin H, Mori M, Matayoshi T, Suzuki R, Yozu R. Division of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan. A 53-year-old man sustained hemodynamic collapse due to a huge right atrial tumor and was transferred to our hospital and underwent a life-saving emergency operation. The tumor arose from the inferolateral wall of the right atrium, occupying almost the whole right atrial cavity and obstructing not only the inflow of the right ventricle but also the orifice of the inferior vena cava. Venous cannulation via the right atrial wall and placing a snare around the inferior vena cava were impossible. With a cardiopulmonary bypass using vacuum-assisted venous drainage, the tumor was successfully resected and the tricuspid valve was replaced with a bioprosthetic valve without snaring the inferior vena cava. Postoperative histological examination demonstrated the tumor to be a large B-cell non-Hodgkin type malignant lymphoma. When the tumor is large and it is difficult to establish total cardiopulmonary bypass, the vacuumassisted cardiopulmonary bypass is a useful option. This can achieve a bloodless operative field and is not blocked by the incoming air, due to the venous drainage being continually pressure-regulated. 10: Perfusion. 2004 Jul;19(4):229-37. Perfusion technique for nonhaemic cardiopulmonary bypass prime in neonates and infants under 6 kg body weight. Merkle F, Boettcher W, Schulz F, Koster A, Huebler M, Hetzer R. Academy for Perfusion, Deutsches Herzzentrum Berlin, Berlin, Germany. BACKGROUND: Cardiopulmonary bypass (CPB) in neonates and infants is associated with significant haemodilution when priming of the CPB circuit is accomplished without transfusion of homologous blood components. The degree of haemodilution and, thus, the requirements for blood transfusion may be reduced when the CPB circuit is miniaturized without compromising patient safety. METHOD: Between January 2002 and October 2003,

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selected neonates and small infants were operated on using a nonhaemic prime extracorporeal circuit. CPB priming volume could be reduced from 300 mL to 190 mL by using a dedicated neonatal CPB console with mast-mounted roller pump heads. Reduction of priming volume resulted from shortening of all CPB lines to the minimum, downsizing of all CPB lines, exclusion of unused CPB components, use of vacuum-assisted venous drainage and from close co-operation between the perfusionist, cardiac surgeon and anaesthesiologist. The reduction in priming volume was achieved without eliminating the arterial line filter as safety device. RESULTS: A total of nine patients weighing between 3.2 and 5.9 kg (mean 4.7 kg) and with a body surface area of 0.22-0.35 m2 (mean 0.29 m2) were operated on with the use of the modified neonatal CPB circuit and a nonhaemic prime. Bypass time varied from 38 to 167 min (mean 96 min). The mean haematocrit on CPB was 22.5% with a range of 17-29%. The postoperative course of all patients was uneventful. CONCLUSION: A significant reduction in CPB priming volume makes nonhaemic prime CPB in neonates and small infants undergoing complex repair of congenital heart defects possible. 11: Perfusion. 2004 Mar;19(2):113-7. In vitro assessment of the vacuum-assisted venous drainage (VAVD) system: risks and benefits. Fiorucci A, Gerometta PS, DeVecchi M, Guzman C, Costantino ML, Arena V. Extracorporeal Circulation Service, Humanitas Gavazzeni, Bergamo, Italy. angelo.fiorucci@gavazzeni.it The vacuum-assisted venous drainage (VAVD) technique has been introduced with the utilization of smallbore venous cannulae to facilitate minimally invasive cardiac surgery and it has found widespread use for traditional surgical approaches. Although this technique was devised to increase venous return, it may cause a reduction of blood flow through a negative pressure effect on the raceway tubing. In this study, the potential of this system to increase the venous drainage was evaluated in vitro together with the measurements of delivered blood flow. The VAVD has been tested in association with normal gravitational drainage or as a substitute for gravitational drainage. The flow was calculated by multiplying the pump rate by the stroke volume and it was simultaneously measured by a magnetic flowmeter. A steady state maximal flow was defined as the flow that could maintain a constant level of fluid in the graduated canister used to act as the patient. Based on our results, the VAVD can increase venous drainage by as much as 50% above baseline levels. However, delivered blood flow may be overestimated, particularly when negative pressure values > 60

Literature Abstracts
mmHg are employed. A 100 mmHg negative pressure may produce an overestimate of blood flow as great as 54% of the measured flow. 12: Perfusion. 2004;19 Suppl 1:S49-55. Bubbles and bypass: an update. Kurusz M, Butler BD. University of Texas Medical Branch, Galveston, TX 77555-0528, USA. Bubbles in the bloodstream are not a normal condition-yet they remain a fact of cardiopulmonary bypass (CPB), having been extensively studied and documented since its inception some 50 years ago. While detectable levels of gaseous microemboli (GME) have decreased significantly in recent years and gross air embolism has been nearly eliminated due to increased awareness of etiologies and technological advances, methods of use of current perfusion systems continue to elicit concerns over how best to totally eliminate GME during openheart procedures. A few studies have correlated adverse neurocognitive manifestations associated with excessive quantities of GME. Newer techniques currently in vogue, such as vacuum-assisted venous drainage, low-prime perfusion circuits, and carbon dioxide flooding of the operative field, have, in some instances, exacerbated the problem of gas embolism or engendered secondary complications in the safe conduct of CPB. Doppler monitoring (circuit or transcranial) primarily remains a research tool to detect GME emanating from the circuit or passing into the patients' cerebral vasculature. Newer developments not yet widely available, such as multiple-frequency harmonics, may finally provide a tool to distinguish particulate microemboli from GME and further delineate the clinical significance of GME. 13: J Thorac Cardiovasc Surg. 2004 Apr;127(4):102631; discussion 1031-2. Minimally invasive technology for mitral valve surgery via left thoracotomy: experience with forty cases. Saunders PC, Grossi EA, Sharony R, Schwartz CF, Ribakove GH, Culliford AT, Delianides J, Baumann FG, Galloway AC, Colvin SB. Department of Surgery, New York University School of Medicine, New York, NY 10016, USA. BACKGROUND: Recent evolution of minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery. These same technological advances have also made the left posterior minithoracotomy approach attractive in complex mitral procedures. METHODS: From 1996 to 2003, 921 isolated mitral valve procedures were performed without sternotomy; 40 (4.3%) of these were performed

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via left posterior minithoracotomy. In the left posterior minithoracotomy group, ages ranged from 18 to 84 years; 36 patients had had previous cardiac surgery (9 on > or =2 occasions). Other factors precluding right thoracotomy included mastectomy/radiation and pectus excavatum. RESULTS: Arterial perfusion was via femoral artery (n = 26) or descending aorta (n = 14); long femoral venous cannulas with vacuum-assisted drainage were used in 39 procedures. Two patients had direct aortic crossclamping, 18 had hypothermic fibrillation, and 20 had balloon endoaortic occlusion. The mean crossclamp and bypass times were 81.9 and 117.2 minutes, respectively. Hospital mortality was 5.0% (2/40); both deaths occurred in octogenarians. There were no injuries to bypass grafts or conversions to sternotomy. Complications included perioperative stroke (2/40; 5.0%), bleeding (2/40; 5.0%), and respiratory failure (1/40; 2.5%); 28 patients (70%) had no postoperative complications. There was no incidence of perioperative myocardial infarction, renal failure, sepsis, or wound infection. The median length of stay was 7 days. CONCLUSIONS: Advances in minimally invasive cardiac surgery technology are readily adaptable to a left-sided minithoracotomy approach to the mitral valve. The left posterior minithoracotomy approach is a valuable option in complicated reoperative mitral procedures with acceptable perioperative morbidity and mortality. 14: Jpn J Thorac Cardiovasc Surg. 2004 Jan;52(1):26-9. Mitral valve replacement through right thoracotomy after previous coronary artery bypass grafting: the usefulness of brachial artery cannulation, perfused ventricular fibrillation with moderate hypothermia, and minimal dissection techniques. Murakami T, Kuinose M, Takagaki M, Inagaki E. Department of Cardiovascular Surgery, Iwakuni National Hospital, 2-5-1 Kuroiso-cho, Iwakuni, Yamaguchi 740-8510, Japan. It has been reported by several authors that a right thoracotomy for mitral valve surgery can be useful after previous coronary aortery bypass grafting (CABG). A 76year-old man with mitral valve regurgitation after previous CABG underwent mitral valve replacement with some modified techniques. Cardiopulmonary bypass was established with right brachial artery cannulation and right femoral venous cannulation with the aid of vacuum-assisted venous drainage. Ventricular fibrillation (VF) was induced by rapid pacing of the ventricle, and mitral valve replacement was performed under perfused VF with moderate hypothermia. The patient's postoperative course was uneventful. This method appears to be a safe and easy alternative mitral valve surgery for complicated cases of this type.

Literature Abstracts
15: Ostomy Wound Manage. 2003 Nov;49(11):52-66. A consensus report on the use of vacuum-assisted closure in chronic, difficult-to-heal wounds. Sibbald RG, Mahoney J; V.A.C. Therapy Canadian Consensus Group. Department of Medicine, University of Toronto, Toronto, Canada. gary.sibbald@utoronto.ca Vacuum-assisted closure is an adjunctive therapy that utilizes negative pressure to remove fluid from open wounds through a sealed dressing and tubing which is connected to a collection container. Although introduced into practice for individuals with chronic wounds, evidence to support its use is limited. To compensate for the current gap between the evidence base and the need for best vacuum-assisted closure practices in the treatment of chronic wounds, the existing evidence base (case reports, case series, and studies) for pressure ulcers, diabetic foot ulcers, heel ulcers, and venous leg ulcers was retrieved and tabulated from relevant literature in PubMed and other sources. In addition, expert opinion was obtained through an 11member Delphi panel of interdisciplinary wound care opinion leaders and educators. The panel included frequent (6) and less-frequent (5) vacuum-assisted closure users. The tabulated responses and the existing literature formed the basis of the best practice statements that serve to guide treatment approaches and stimulate further study. 16: J Artif Organs. 2003;6(1):20-4. Vacuum-assisted venous drainage in single-access minimally invasive cardiac surgery. Kiyama H, Imazeki T, Katayama Mukouyama M, Yamauti N. Y, Murai N,

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maze procedures, free hemoglobin was measured to evaluate hemolysis. Vacuum-assisted venous drainage was required in 77 (72.6%) patients. Except for a smaller body surface area in the gravity group (P = 0.0118), patient characteristics did not differ significantly between the two groups. Free hemoglobin 60 mins after the beginning of cardiopulmonary bypass was higher in the vacuum group than in the gravity group (21.5 +/- 7.3 vs 11.1 +/- 7.1 mg/dl, P = 0.0284). Operative mortality and morbidity did not differ significantly between the groups. We found vacuum-assisted venous drainage to be a safe, simple, and effective technique in cases of minimally invasive cardiac surgery. However, there is a potential risk of hemolysis and air embolism, as shown in our findings and previous reports. 17: J Thorac Cardiovasc Surg. 2003 Sep;126(3):680-7. Vacuum-assisted venous return reduces blood usage. Banbury MK, White JA, Blackstone EH, Cosgrove DM 3rd. Departments of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue/ Desk F25, Cleveland, OH 44195, USA. banburm@ccf.org OBJECTIVE: To determine whether vacuum-assisted venous return has clinical advantages over conventional gravity drainage apart from allowing the use of smaller cannulas and shorter tubing. METHODS: A total of 150 valve operations were performed at our institution between February and July 1999 using vacuum-assisted venous return with small venous cannulas connected to short tubing. These were compared with (1) 83 valve operations performed between April 1997 and January 1998 using the initial version of vacuum-assisted venous return, and (2) 124 valve operations performed between January and April of 1997 using conventional gravity drainage. Priming volume, hematocrit value, red blood cell usage, and total blood product usage were compared multivariably. These comparisons were covariate and propensity adjusted for dissimilarities between the groups and confirmed by propensity-matched pairs analysis. RESULTS: Priming volume was 1.4 +/- 0.4 L for small-cannula vacuum-assisted venous return, 1.7 +/- 0.4 L for initial vacuum-assisted venous return, and 2.0 +/- 0.4 L for gravity drainage (P <.0001). Smaller priming resulted in higher hematocrit values both at the beginning of cardiopulmonary bypass (27% +/- 5% compared with 26% +/- 4% and 25% +/- 4%, respectively, P <.0001) and at the end (30% +/- 4% compared with 28% +/- 4% and 27% +/- 4%, respectively, P <.0001). Red cell transfusions were used in 17% of the patients having smallcannula vacuum-assisted venous return, 27% of the initial patients having vacuum-assisted venous return, and 37% of the patients having gravity drainage (P =.001);

Department of Cardiovascular and Thoracic Surgery, Dokkyo University Koshigaya Hospital, Saitama, Japan. hykiyama@da2.so-net.ne.jp This retrospective study evaluated the influence of vacuum-assisted venous drainage in single-access minimally invasive cardiac surgery. A total of 104 patients who underwent cardiac surgery via minimal access incision were included in this study. Cardiopulmonary bypass was initiated with gravity alone, and vacuumassisted venous drainage was applied only when the bypass flow was 2.2 l/min/m2 or less. We compared intraoperative variables of the patients to whom vacuumassisted venous drainage (vacuum group) was applied with those who underwent gravity venous drainage alone (gravity group). In the 13 patients who most recently underwent isolated valve operations without

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total blood product usage was 19%, 27%, and 39%, respectively (P =.002). Although ministernotomy also was associated with reduced blood product usage (P <.004), propensity matching on type of sternotomy confirmed the association of vacuum-assisted venous return with lowered blood product usage. CONCLUSIONS: Vacuum-assisted venous return results in (1) higher hematocrit values during cardiopulmonary bypass and (2) decreased red cell and total blood product usage. 18: Ann Thorac Surg. 2002 Dec;74(6):2132-7. Does vacuum-assisted venous drainage increase gaseous microemboli during cardiopulmonary bypass? Jones TJ, Deal DD, Vernon JC, Blackburn N, Stump DA. Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1009, USA. BACKGROUND: Vacuum-assisted venous drainage enables adequate drainage through small-diameter cannulas but concerns are that it results in more gaseous microemboli delivered to the patient. METHODS: Five identical embolus detectors monitored the propagation of entrained air through a cardiopulmonary bypass (CPB) model. The ability of the CPB circuit to remove gaseous microemboli was studied with vacuum-assisted venous drainage and gravity siphon venous drainage using different pump speeds and rates of gaseous microemboli delivery. RESULTS: Under all conditions entrained venous air resulted in the detection of gaseous microemboli in the perfusate after the arterial filter. In blood-primed circuits, increased flow rates and higher levels of vacuumassisted venous drainage were independently associated with increased gaseous microemboli counts in the arterial line. Vacuum-assisted venous drainage at -40 mm Hg did not significantly increase gaseous microemboli activity when compared with gravity siphon venous drainage at 4 L/min flow rate. CONCLUSIONS: Vacuum-assisted venous drainage at 40 mm Hg does not statistically reduce the ability of the CPB circuit to remove gaseous microemboli at lower pump rates. High levels of vacuum and increased pump flow rates should be avoided. Air should not be introduced into the venous line. 19: Heart Surg Forum. 2002;5(3):285-8. Vacuum-assisted venous drainage does not increase the neurological risk. Carrier M, Cyr A, Voisine P, Pellerin M, Perrault LP, Cartier R, Page P, Hebert Y, Bouchard D, Poirier N. Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada. carrier@icm.umontreal.ca

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BACKGROUND: Vacuum-assisted venous drainage (VAVD) with negative pressure applied to integral sealed-hardshell venous reservoir facilitates valvular surgery through minimally invasive approaches. Despite concerns regarding air entrainment from the right atrium, cerebral microemboli of air and neurological complications, VAVD was used in patients who underwent valvular surgery throughout the last two years in our institution. METHODS: We compared the rate of neurological complications in patients who underwent surgery with and without VAVD from June 1997 to July 2001. VAVD was added to solid venous reservoirs with membrane oxygenators and arterial filters. Clinical results were prospectively entered in our valve database and were used for the analysis. RESULTS: Eight hundred twenty-two consecutive patients averaging 65 +/- 11 years of age underwent aortic, mitral and tricuspid valve replacements including 40 redos (40/822, 5%) and 265 associated CABG (265/822, 32%) with VAVD in 1999 to 2001 compared to 723 patients averaging 63 +/- 11 years of age (p = 0.01) who underwent the same procedures with 79 redos (79/723, 11%) and 177 CABG (177/723, 24%) without VAVD in 1997 to 1999. CPB time averaged 117 +/- 50 minutes in VAVD patients compared to 108 +/43 minutes in those without VAVD (p = 0.001). Thirtyday mortality averaged 5% (39/822) in patients with VAVD and 4% (30/723) in those without VAVD (p = 0.6). Seven patients of the VAVD group (7/822, 1%) and 11 patients without VAVD (11/723, 1.5%, p = 0.2) suffered from temporary or permanent neurological deficit. CONCLUSION: VAVD is a useful adjunct to modern cardiopulmonary bypass systems. When used with appropriate care, VAVD does not appear to significantly increase air microemboli and is not associated with an increased neurological risk following valvular surgery. 20: J Urol. 2003 Jan;169(1):75-8; discussion 78. Experience with an elective vacuum assisted cardiopulmonary bypass in the surgical treatment of renal neoplasms extending into the right atrium. Tasca A, Abatangelo G, Ferrarese P, Piccin C, Fabbri A, Musi L. Department of Urology, S Bortolo Hospital, Vicenza, Italy. PURPOSE: We evaluate the results of an elective cardiopulmonary bypass conceived to minimize the surgical risk related to its use with temporary circulatory arrest and deep hypothermia in the treatment of patients with renal tumor extending into the right atrium. MATERIALS AND METHODS: From July 1996 to December 2000, 19 patients with renal neoplasm and venous involvement were admitted to our department. Three

Literature Abstracts
patients 4, 57 and 58 years old with a right (2) and left (1) renal tumor extending into the right atrium underwent radical nephrectomy and tumor thrombus removal using a normothermic cardiopulmonary bypass. The bypass circuit was connected with a vacuum assisted venous drainage giving a negative pressure of 20 to 40 mm. Hg. Neither circulatory arrest nor hypothermia was used. Tumor thrombus was extracted through a longitudinal "cavotomy" and removed along with the kidney. RESULTS: Total cardiopulmonary bypass time was 14, 19 and 22 minutes, respectively. No intraoperative or postoperative complications due to surgical technique occurred. No significant bleeding was observed at the time of cavotomy and all neoplastic tissue was removed. Pathological examination documented renal cell carcinoma in 2 cases and Wilms tumor in 1. All the patients are alive 30, 42 and 15 months, respectively, after the operation. CONCLUSIONS: Normothermic cardiopulmonary bypass with vacuum assisted venous drainage makes circulatory arrest and hypothermia unnecessary and avoids the potential complications associated with these procedures. With respect to veno-venous shunts this technique guarantees complete surgical control of the thrombus and avoids the need for extensive dissection of the retrohepatic vena cava and Pringle maneuver. 21: Perfusion. 2002 Sep;17(5):383-90. A new top-loading venous bag provides vacuumassisted venous drainage. Tamari Y, Lee-Sensiba K, Beck J, Chan R, Salogub M, Hall M, Lee T, Ganju R, Mongero L. Department of Surgery, North Shore University Hospital, Manhasset, New York, USA. ytamari@cirtec.com A new venous bag has been developed, prototyped, and tested. The new bag has its inlet, outlet purge, and infusion tubes extending upward from the top of the bag, and are threaded through, bonded to, and sealed within a flat rigid top plate. This design allows the bag to be hung from its top plate by its tubes. It also allows the bag to be: 1) dropped into or removed from its holder, as is done with existing hard-shell reservoirs so that its weight pulls it into the holder without the need for eyelets and hooks and 2) placed closer to the floor so that gravity drainage is facilitated. The V-Bag (VB) is easily sealed within an accompanying rigid housing. Once sealed, vacuum applied to the housing is transmitted across the flexible walls of the bag to the venous blood. Thus, vacuum-assisted venous drainage (VAVD) is obtained as it is with a hard-shell reservoir, but without any contact of air with the blood. Bench tests, using a circuit that simulated the venous side of the cardiopulmonary bypass (CPB) circuit, showed that applying suction to the housing increased venous flow, and the fractional increase in flow was not a function of the venous

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cannula, but of the level of vacuum applied. In the gravity drainage mode, the bubble counts at the outlet of the V-Bag compared to two other bags were lower at any pumping condition. When used in the VAVD mode, bubble counts were two orders of magnitude lower than when using kinetically assisted venous drainage (KAVD) with a centrifugal pump. Results obtained with the VB suggest its clinical usefulness. 22: J Extra Corpor Technol. 2002 Jun;34(2):115-7. Laboratory evaluation of the limitations of positive pressure safety valves on hard-shell venous reservoirs. Almany DK, Sistino JJ. Cardiovascular Perfusion Program, Medical University of South Carolina, Charleston 29425, USA. Vacuum-assisted venous drainage (VAVD) is a technique used to increase venous return during cardiopulmonary bypass (CPB). However, VAVD has created some new safety concerns. One potential problem is the pressurization of the venous reservoir in the event of vacuum failure. To prevent this overpressurization, a positive pressure release valve (PPRV) is placed on the venous reservoir. The purpose of this study was to determine if there is a difference in the pressurization of venous reservoirs using various PPRVs. The method of this study included evaluation of four different venous reservoirs and their associated PPRVs. Each reservoir was completely sealed, and two roller pumps with 1/4in tubing were connected to the reservoir suction inlet. The roller pumps were calibrated, and a disposable pressure transducer was used to measure pressure at the venous inlet. Each reservoir was first sealed and then pressurized to test the occlusion of the roller heads. The PPRVs were tested by measuring the venous inlet pressure at a range of suction flow rates from 0-5 L/min. Linear regression analysis was performed to predict the venous inlet pressure from the rate of suction flow for each PPRV. The PPRV in the Baxter, Gish, and Gambro reservoirs maintained a low reservoir pressure (<40 mmHg) even at excessive suction flow rates (3-5 L/min). The PPRV in the Medtronic reservoir allowed excessive pressures (>40 mmHg) even at low flow rates (1-2 L/min). It is recommended that any reservoir used for VAVD be evaluated in a similar manner to determine whether it is safe under the maximal suction and vent flow conditions possible during clinical practice. 23: J Extra Corpor Technol. 2002 Jun;34(2):111-4. Laboratory evaluation of the pressure flow characteristics of venous cannulas during vacuum-assisted venous drainage. Humphries K, Sistino JJ.

Literature Abstracts
Cardiovascular Perfusion Program, Medical University of South Carolina, Charleston 29425, USA. Vacuum-assisted venous drainage (VAVD) is frequently used to increase venous return through smaller venous cannula and reduced venous line size. The purpose of this study is to determine the maximal flow rates achieved through various venous cannula with varying amounts of negative pressure applied during VAVD. The first test circuit consisted of 25 different venous cannulae connected to 3/8 inner diameter tubing on the positive side of a centrifugal pump. Flows through the cannula were measured at a line pressure of 20, 40, 60, and 80 mmHg. The second circuit consisted of the test cannula connected to 3/8-in inner diameter tubing, a hard-shell venous reservoir, and flow probe placed on the venous line. Using a vacuum regulator and venous line pressure monitor, flow rates were measured through each cannula at -20, -40, -60, and -80 mmHg of vacuum. The results show a mean correlation of 0.989 between the two methods of flow measurement (p < .001). Mean flow rates were established at 40 and 80 mmHg using both methods. For each 40 mmHg increase using vacuum, blood flow was increased by 42.08 +/- 0.09%. These data have been incorporated into a chart to allow the perfusionist to identify the negative pressure necessary to achieve venous return when using specific venous cannula during VAVD. 24: J Cardiovasc Surg (Torino). 2002 Aug;43(4):475-7. Direct minimally invasive approach for aortic root replacement. Klokocovnik T. Department of Cardiothoracic Surgery, University Medical Centre Ljubljana, Slovenia. tomi.klokocovnik@siol.net The author describes a minimally invasive approach for aortic insufficiency associated with severe calcification of the ascending aorta. The Bentall operation was easily performed through an 8 cm skin incision affording excellent exposure of the operating field, and with the use of CPB with vacuum-assisted venous drainage and clamping the aorta with a Casgrove flex clamp. 25: Thorac Cardiovasc Surg. 2002 Apr;50(2):100-1. Vacuum-assisted venous drainage in complex congenital cardiac surgery. Walther T, Tsang V, Hawkey D, de Leval M. 27: Ann Thorac Surg. 2002 Feb;73(2):671-2. Klinik fur Herzchirurgie, Herzzentrum, Unviersitat Leipzig, Germany. walt@mdizin.uni-leipzig.de Here, we report on a case of temporary neurological

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damage following conduit replacement from the right ventricle to pulmonary artery during which vacuumassisted venous drainage was used. We will discuss the benefits and risks of this technique with potential arterial air embolism despite the use of arterial line filters. We will also make recommendations for avoiding such complications. 26: J Extra Corpor Technol. 2002 Mar;34(1):24-8. Vacuum-assisted venous drainage: to air or not to air, that is the question. Has the bubble burst? Willcox TW. Clinical Perfusion, Cardiothoracic Unit, Green Lane Hospital, Auckland, New Zealand. Assisted venous drainage is a recent development in cardiopulmonary bypass (CPB) and was introduced to overcome limitations in achieving adequate blood flow through small diameter cannulas used in minimally invasive surgery. The more common application, vacuum assisted venous drainage (VAVD) is now widely used in both adult and pediatric CPB. During a clinical investigation into pharmacological cerebral protection at Green Lane Hospital, we repeatedly observed evidence of emboli in the right common carotid artery following both entrainment of air into the venous line, and also, reductions in the blood level of the hard-shell venous reservior. We subsequently embarked upon a series of in vitro experiments designed to identify sources of emboli from the CPB circuit,and to evaluate the ability of CPB circuit components to remove air entrained into the venous line under conditions of both gravity and vacuum assisted venous drainage. Initial experiments revealed design features of certain hard-shell venous reservoirs that generated gaseous emboli. In further studies using adult circuits, entrainment of air into the venous line under conditions of conventional gravity venous drainage resulted in emboli distal to the arterial filter. When these studies were repeated using VAVD, arterial line emboli increased eight to tenfold. Initial experiments with a pediatric circuit showed similar findings. Cerebral emboli during CPB have been positively correlated with increasing neurocognitive deficits. The application of VAVD has been employed clinically without any significant redesign of the components of the CPB circuit. While VAVD may be efficacious in certain scenarios, a thorough understanding of its influence on CPB is essential. Advantages must be balanced against potential hazards. The safe use of VAVD necessitates refinement of perfusion techniques, judicious choice of application, and further development of the CPB circuit.

Open inferior vena caval anastomosis during bicaval heart transplantation.

Literature Abstracts
Aklog L, Sepic J, Filsoufi F, Byrne JG, Adams DH. Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. laklog@partners.org Performing a precise inferior vena caval (IVC) anastomosis during bicaval orthotopic heart transplantation can sometimes be challenging because of crowding of the operative field by the venous cannula and tourniquet. We performed bicaval orthotopic heart transplantation in 10 patients using an open IVC anastomotic technique with vacuum-assisted venous drainage. A long venous cannula was passed into the IVC through the femoral vein. The IVC anastomosis was performed after removing the IVC tourniquet under vacuumassisted venous drainage. A precise edge-to-edge IVC anastomosis was successfully performed in all patients. This technique may result in greater anastomotic precision and improved outcomes. 28: Perfusion. 2002 Jan;17(1):57-61. Biochemical evaluation of vacuum-assisted venous drainage: a randomized, prospective study. Bevilacqua S, Matteucci S, Ferrarini M, Kacila M, Ripoli A, Baroni A, Mercogliano D, Glauber M, Ferrazzi P. Cardiac Surgery Department, Istituto di Fisiologia Clinica, Consiglio Nazionale delle Ricerche, Massa, Italy. bevilacqua@ifc.pi.cnr.it AIMS OF THE STUDY: In this prospective, randomized study, we investigate the potential advantages of vacuum-assisted venous drainage (VAVD), compared to gravitational drainage (GD), in patients undergoing firsttime coronary artery bypass graft (CABG) surgery, concerning biochemical markers of organ and blood cell damage. MATERIALS AND METHODS: Seventy-two consecutive patients were randomized into two groups ['Vacuum' (VAVD) n=36; 'Not vacuum' (GD) n=36]. VAVD was achieved using a wall vacuum source and with a suction regulator connected to the vent port of the hardshell venous reservoir. In the VAVD group, we used 28-French venous cannulas, and 36-French in the GD group. In the VAVD group, we measured arterial perfusion flow (APF) and the venous reservoir volume (VRV) with and without vacuum application just after starting extracorporeal circulation (ECC). Six blood samples were drawn at different times before, during and after ECC. Routine blood tests were performed to evaluate hemolysis, and hepatic and renal function. RESULTS: The two groups were similar in terms of preoperative and operative characteristics. There were no significant differences in biochemical markers of organ function or hemolysis between the two groups. In the VAVD patients, platelet count was higher at 24 h after the end of the operation (VAVD 151.77+/-50.28 microl

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versus Not vacuum 124.93+/-41.60 microl, p=0.028). With the narrower venous cannulas (28-French), only VAVD achieved a satisfactory APF (VAVD 2.35+/-0.38 l/ min/m2 versus GD 1.88+/-0.27 l/min/m2, p=0.002), with a larger VRV (VAVD 1091.67+/-421 ml versus GD 808.33+/-284.31 ml, p=0.025). CONCLUSION: Vacuum-assisted venous drainage is a technique comparable to gravitational drainage with regard to hemolysis and organ perfusion. It allows better perfusion flow and heart decompression with smaller venous cannulas. This study suggests reduced platelet consumption with VAVD. 29: ASAIO J. 2001 Nov-Dec;47(6):651-4. Vacuum assisted venous drainage does not increase trauma to blood cells. Mueller XM, Tevaearai HT, Horisberger J, Augstburger M, Burki M, von Segesser LK. Clinic for Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Although gravity drainage has been the standard technique for cardiopulmonary bypass (CPB), the development of min imally invasive techniques for cardiac surgery has renewed interest in using vacuum assisted venous drainage (VAVD) Dideco (Mirandola, Italy) has modified the D903 Avant oxygenator to apply a vacuum to its venous reservoir. The impact of VAVD on blood damage with this device is analyzed. Six calves (mean body weight, 71.3 +/- 4.1 kg) were connected to CPB by jugular venous and carotid arterial cannu lation, with a flow rate of 4-4.51 L/min for 6 h. They were assigned to gravity drainage (standard D903 Avant oxygen ator, n = 3) or VAVD (modified D903 Avant oxygenator, n = 3). The animals were allowed to survive for 7 days. A standard battery of blood samples was taken before bypass, throughout bypass, and 24 h, 48 h, and 7 days after bypass. Analysis of variance was used for repeated measurements. Thrombocyte and white blood cell counts, corrected by hematocrit and normalized by prebypass values, were not significantly different between groups throughout all study periods. The same holds true for hemolytic parameters (lactate dehydrogenase [LDH] and plasma hemoglobin). Both peaked at 24 hr in the standard and VAVD groups: LDH, 2,845 +/- 974 IU/L vs. 2,537 +/- 476 IU/L (p = 0.65), respectively; and plasma hemoglobin, 115 +/- 31 mg/L vs. 89 +/- 455 mg/L (p = 0.45), respectively. In this experimental setup with prolonged perfusion time, VAVD does not increase trauma to blood cells in comparison with standard gravity drainage. 30: Ann Thorac Surg. 2001 Nov;72(5):1727-8. Cerebrovascular accident after vacuum-assisted venous drainage in a Fontan patient: a cautionary tale.

Literature Abstracts
Jahangiri M, Rayner A, Keogh B, Lincoln C. Department of Cardiac Surgery, Anesthesia, and Perfusion, Royal Brompton Hospital, London, England. Vacuum-assisted venous drainage was used in a 24year-old woman who underwent a redo Fontan procedure. She developed a hemiparesis, which is thought to be caused by cerebral air embolism. 31: Eur J Cardiothorac Surg. 2001 Sep;20(3):621-6. Clinical application of vacuum-assisted cardiopulmonary bypass with a pressure relief valve. Hayashi Y, Kagisaki K, Yamaguchi T, Sakaguchi T, Naka Y, Sawa Y, Ohtake S, Matsuda H. Department of Surgery, Course of Interventional Medicine (E1), Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, 565-0871, Osaka, Japan. OBJECTIVES: Hemodilution induced by cardiopulmonary bypass (CPB) often prevents open heart operations without blood transfusion because of a large CPBpriming volume. A vacuum-assisted venous drainage system appears to overcome this problem and our previous experimental study demonstrated the beneficial effect of a vacuum-assisted CPB with a pressure relief valve. In this study, we clinically applied this novel system, and evaluated its efficacy by comparing it with the results of a conventional siphon-dependent drainage system. METHODS: Sixty patients undergoing open heart operation were divided into Group V (vacuum-assisted system, n=30) and Group S (siphon-dependent system, n=30). The vacuum-assisted system contains a powerful vacuum generator and a pressure relief valve to keep the negative pressure in the reservoir constant when the blood suction is used. RESULTS: The CPB-priming volume was significantly smaller in Group V (V vs. S: 1071+/-88 vs. 1405+/-137 ml; P<0.01), resulting in the lower hemodilution in Group V evidenced by the minimum hemoglobin level (V vs. S: 6.83+/-1.06 vs. 5.78+/-0.79 mg/dl; P<0.01) and blood transfusion rate (V vs. S: 9 vs. 20%; P<0.01). There were no significant differences in the plasma free hemoglobin level and the reduction ratio of plasma haptoglobin between the groups. CONCLUSIONS: These data demonstrate that this vacuum-assisted CPB can provide simplification of the CPB circuit, resulting in a smaller CPB-priming volume and lower hemodilution. This vacuum-assisted CPB may attenuate the negative effect of CPB by minimizing hemodilution and appears to be a useful modification to accomplish no blood-requiring open heart operations. 32: Perfusion. 2001 Jul;16(4):313-8.

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Haemolysis due to active venous drainage during cardiopulmonary bypass: comparison of two different techniques. Cirri S, Negri L, Babbini M, Latis G, Khlat B, Tarelli G, Panisi P, Mazzaro E, Bellisario A, Borghetti B, Bordignon F, Ferrara M, Pavan H, Meco M. Anaesthesiology and Intensive Care Department, Instituto Clinico Sant'Ambrogio, Milan, Italy. To facilitate mini-access for cardiac surgery, two different methods of active venous drainage are used: vacuum assisted drainage and centrifugal pump aspiration on the venous line. The aim of this study was to compare the haemolysis produced using these two techniques. From June to December 1999, 50 consecutive patients were operated on using a ministernotomy. All of these patients had valvular surgery for either valve repair or valve replacement (9 MVRepair, 11 MVR, 29 AVR, 1 AVR + MVR). They were randomized into two groups: Group A, 25 patients who underwent surgery where vacuum assisted drainage was used, and Group B, 25 patients where kinetic asssisted venous drainage with centrifugal pump venous aspiration was used. Patient characteristics of both groups were similar for age, gender, body weight, body surface area, height, cardiopulmonary bypass (CPB) time, aortic crossclamp time, priming volume, cardioplegia volume, haemoglobin concentration, haematocrit, serum creatinine, bilirubin, lactate dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (sGOT), serum glutamic pyruvic transaminase (sGPT), aptoglobin, reticulocytes, and platelet count. We checked all these laboratory parameters preoperatively, at the end of CPB, and 2 and 24 h after operation. We also checked haemoglobinuria at these same time points. We assessed blood loss at 6, 12, and 24 h after the operation and calculated total postoperative bleeding. There was a tendency towards a greater increase in LDH, sGOT and sGPT in Group A more than in Group B, but these data did not reach statistical significance. Platelet count was always lower in Group A and aptoglobin increased in Group A more than in Group B. More patients in Group A had haemoglobinuria. These findings indicate that haemolysis is increased more in patients treated with vacuum assisted drainage, when compared to the rise in haemolysis in those treated with centrifugal pump venous drainage. Total bleeding is also greater in Group A. 33: J Extra Corpor Technol. 2001 Feb;33(1):15-8. In-vitro evaluation of the hemolytic effects of augmented venous drainage. Mathews RK, Sistino JJ. Extracorporeal Circulation Technology Program, College of Health Professions, Medical University of South Carolina, USA. respfusion@aol.com

Literature Abstracts
Augmentation of venous drainage with either kineticassisted drainage (KAVD) or vacuum-assisted (VAVD) has been used clinically in order to overcome added venous resistance due to smaller venous cannulae or tubing. This in-vitro study evaluates the extent of hemolysis and sub-lethal red blood cell membrane damage than occurs with augmented (kinetic or vacuum) when compared to conventional gravity drainage. Four trials were conducted using each test circuit. The circuits were primed with 6 liters of fresh heparinized bovine blood, which was diluted to a hematocrit of 32% and was recirculated at 5 L/min for 8 hours. Hemolysis was determined by the change in plasma free-hemoglobin (Hb), hematocrit, and potassium at two hour intervals. The red cell osmotic fragility index was used to quantify the sub-lethal red blood cell membrane damage and was also measured every two hours. After 8 hours, the mean +/- SD of the plasma free-Hb were: 96.27 +/69.45 mg/dl for gravity, 83.87 +/- 48.14 mg/dl for vacuum-assist, and 134.45 +/-83.78 mg/dl for kineticassist. Two-hour increases in the plasma free-Hb revealed the following median values (mg/dL/2 h): 16.90 for gravity, 13.75 for vacuum-assist, and 19.40 for kinetic-assist. Analysis of the two-hour increases in plasma free-Hb with Kruskal-Wallis One-Way ANOVA did not reveal a significant difference among the groups. After 8 hours, the red cell osmotic fragility test results at the 0.55% sodium chloride concentration were compared. The medians of the percent hemolysis were 52.67% for gravity, 49.8% for vacuum-assist, and 57.2% for kinetic-assist. Analysis with the KruskalWallis Wallis One-Way ANOVA did not reveal a significant difference among the groups. Therefore, there is no significant increase in hemolysis or sub-lethal red blood cell membrane damage associated with the use of augmented venous drainage. 34: Ann Thorac Surg. 2001 Apr;71(4):1369-71. Venoarterial air embolus: a complication of vacuumassisted venous drainage. Davila RM, Rawles T, Mack MJ. Cardiopulmonary Research Science Technology, Institute, Dallas, Texas, USA. Minimal access techniques with cardiopulmonary bypass use smaller cannula systems for management of cardiopulmonary bypass. To augment flow rates through the smaller cannula, the technique of vacuumassisted venous drainage has been used. We describe a complication of vacuum-assisted venous drainage by inadvertent positive pressurization of the venous circuit resulting in a paradoxic air embolus across a patent atrial septal defect. Hazards of the current cardiopulmonary bypass systems and techniques for avoiding this potential complication are discussed. 35: J Card Surg. 2000 Jan-Feb;15(1):35-42.

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Cardiac valve operations using a partial sternotomy (lower half) technique. Doty DB, Flores JH, Doty JR. Department of Surgery, LDS Hospital, Salt Lake City, Utah, USA. BACKGROUND AND AIM: Operations on cardiac valves are being performed more frequently through smaller incisions than traditional midline sternotomy. A variety of alternate incisions have been used, but most of the interest appears to focus on partial sternotomy. The purpose of the study was to review results using a partial lower sternotomy for cardiac valve operations. METHODS: A standard partial lower one-half or twothirds sternotomy was used for cardiac valve operations in 112 patients. The sternum was divided transversely in the third or second intercostal space and vertically from that point through the xyphoid process. Standard instruments and retraction devices were used. This incision provided adequate exposure for even complex operations to be performed. Small cannulae were placed into the aorta and heart through the primary incision for cardiopulmonary bypass. Vacuum-assisted venous drainage was used. RESULTS: Seventy-four single valve operations were performed. There were 35 double valve and 5 triple valve operations (35.4%) performed. Operative mortality (5.3%) and major complication rates were comparable to full the sternotomy approach. CONCLUSIONS: Partial sternotomy (lower half) provides a smaller incision through which virtually all cardiac valve operations may be performed. Results achieved with this approach are similar to those associated with full sternotomy. The smaller incision is appreciated by patients. 36: J Thorac Cardiovasc Surg. 2000 Nov;120(5):85662. Assisted venous drainage presents the risk of undetected air microembolism. Lapietra A, Grossi EA, Pua BB, Esposito RA, Galloway AC, Derivaux CC, Glassman LR, Culliford AT, Ribakove GH, Colvin SB. Department of Surgery, Division of Cardiothoracic Surgery, New York University School of Medicine, New York, NY, USA. OBJECTIVES: The proliferation of minimally invasive cardiac surgery has increased dependence on augmented venous return techniques for cardiopulmonary bypass. Such augmented techniques have the potential to introduce venous air emboli, which can pass to the patient. We examined the potential for the transmission of air emboli with different augmented venous return tech-

Literature Abstracts
niques. METHODS: In vitro bypass systems with augmented venous drainage were created with either kinetically augmented or vacuum-augmented venous return. Roller or centrifugal pumps were used for arterial perfusion in combination with a hollow fiber oxygenator and a 40micrometer arterial filter. Air was introduced into the venous line via an open 25-gauge needle. Test conditions involved varying the amount of negative venous pressure, the augmented venous return technique, and the arterial pump type. Measurements were recorded at the following sites: pre-arterial pump, post-arterial pump, post-oxygenator, and patient side. RESULTS: Kinetically augmented venous return quickly filled the centrifugal venous pump with macrobubbles requiring continuous manual clearing; a steady state to test for air embolism could not be achieved. Vacuumaugmented venous return handled the air leakage satisfactorily and microbubbles per minute were measured. Higher vacuum pressures resulted in delivery of signific antly more microbubbles to the "patient" (P <.001). The use of an arterial centrifugal pump was associated with fewer microbubbles (P =.02). CONCLUSIONS: Some augmented venous return configurations permit a significant quantity of microbubbles to reach the patient despite filtration. A centrifugal pump has air-handling disadvantages when used for kinetic venous drainage, but when used as an arterial pump in combination with vacuum-assisted venous drainage it aids in clearing air emboli. 37: J Extra Corpor Technol. 1999 Dec;31(4):195-201. Hematological effects of a low-prime neonatal cardiopulmonary bypass circuit utilizing vacuum-assisted venous return in the porcine model. Ahlberg K, Sistino JJ, Nemoto S. Medical University of South Carolina, Department of Extracorporeal Circulation Technology, Charleston, USA. Limiting hemodilution in neonates is difficult when extracorporeal circuits require priming volumes that are 2 to 3 times the blood volume of the newborn patient. This extreme hemodilution contributes to the development of significant postbypass coagulation disturbances. The purpose of this project was to design a lowprime neonatal bypass circuit and evaluate the coagulation status after reduced hemodilution. The null hypothesis stated there is no significant difference in the measured coagulation parameters between the lowprime circuit and the standard high-prime circuit. Four neonatal piglets (2-4 kg) were divided into two groups and placed on cardiopulmonary bypass using either a low- (200 ml) or high-prime (500 ml) circuit. Both groups were cooled to 20 degrees C, and, following cardioplegic arrest, underwent circulatory arrest for 20 minutes. The low-prime circuit used vacuum-assisted

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venous drainage, which permitted the circuit to be at the patient level. The high-prime circuit required fresh washed donor red blood cells to maintain the hematocrit in the desired range of 15-20%. The platelet count on bypass decreased by 60 +/- 1.0% in the low-prime group versus 79.6 +/- 0.1% in the high-prime group. Following bypass, the platelet count was reduced by 38.3 +/- 14.3% in the low-prime versus 60.2 +/- 2.6% in the high-prime group. During rewarming, the mean heparinase activated clotting time (ACT) increased 5.1% above baseline in the low-prime group and 53.5% above baseline in the high-prime group. Mean plasmafree hemoglobin levels increased 40.4 mg/dl in the lowprime group versus 62.1 mg/dl in the high-prime group during bypass. This laboratory evaluation of a low-prime neonatal circuit demonstrates that coagulation disturbances often present in neonates can be reduced with the use of a low-prime circuit. 38: Artif Organs. 2000 Jun;24(6):450-3. Vacuum assisted cardiopulmonary bypass in minimally invasive cardiac surgery: its feasibility and effects on hemolysis. Shin H, Yozu R, Maehara T, Matayoshi T, Morita M, Kawai Y, Yamada T, Kawada S. Division of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan. The present study describes a cardiopulmonary bypass (CPB) technique that incorporates vacuum assisted venous drainage and arterial return using a centrifugal pump in minimally invasive cardiac surgery (MICS). The technique was performed on 40 patients scheduled to undergo MICS. The proposed CPB technique enables a good operative field to be obtained even through a limited incision through the use of peripheral cannulation using small cannulae. Vacuum pressure was applied to the venous reservoir (-43 +/- 14 mm Hg) to maintain adequate CPB flow (>2.4 L x min-1 x M-2). The effects of CPB on hemolysis were subsequently compared between patients who underwent the proposed procedure (MICS group; n = 6) and a control group who underwent coronary arterial bypass grafting (CABG group; n = 6) with conventional CPB. Plasma free hemoglobin (FHb) increased and plasma haptoglobin (Hp) decreased during CPB in both groups, with no significant difference between the groups. By the next day, FHb had returned to pre-CPB levels whereas Hp remained lower in both groups. Again, these values did not differ significantly between groups. Thus, we conclude that the proposed CPB technique is useful in MICS with acceptable effects on hemolysis. 39: Perfusion. 2000 Jan;15(1):63-7. Vacuum-assisted venous return in pediatric cardiopul-

Literature Abstracts
monary bypass. Berryessa R, Wiencek R, Jacobson J, Hollingshead D, Farmer K, Cahill G. Baxter Perfusion Services and Cardiovascular Surgery Associates, Las Vegas, Nevada, USA. Vacuum-assisted venous return (VAVR) has been reported to offer benefits for adults undergoing cardiopulmonary bypass (CPB), such as improved venous return, lowering priming volume (by eliminating the need to prime the venous line), and the use of smaller venous cannulae. All these benefits would be of particular value in pediatric perfusion because of the unique challenges of these smaller patients and the relatively large components of the CPB circuit. We have been using VAVR in children since the early summer of 1998 after we became comfortable with the technique and convinced of its efficacy in adults. Ours is a medium-sized pediatric caseload of slightly more than 100 CPB cases per year. With that caseload, it is most effective for us to minimize the inventory of different sizes of disposables used. We have opted for an oxygenator/reservoir that has a maximum flow of 4 liters with a priming volume of about 1 liter. We have been unhappy with the large prime volume in infants and earlier, in 1997-1998, were using a smaller prime oxygenator/reservoir until it was recalled. Faced again with a larger priming volume in the infants, we decided to try vacuum to decrease hemodilution and to evaluate other possible benefits. Through the use of VAVR, we have been able to decrease our priming volume, use smaller venous cannulae, and have more consistent return while experiencing no adverse effects of VAVR in our pediatric cardiac surgery patients. 40: J Indian Med Assoc. 1999 Oct;97(10):436-7, 441. Advances in perfusion technology--an overview. Ogella DA. Perfusion Services, Cleveland Clinic Foundation, USA. The introduction of minimally invasive approaches to cardiac surgery offered the opportunity to reduce patient's pain associated with median stemotomy as well as infection and postoperative bleeding. This technique required the use of one small venous cannula necessitating the implementation of kinetic assisted venous drainage (KAVD). However, KAVD proved costly due to the use of a centrifugal pump and could be de-primed if air was introduced into the venous line. Vacuum assisted venous drainage (VAVD), an easy to learn technique, was proved to be a better, safe and less expensive alternative as it required lower prime and small cannulae. Blunt trauma could also be avoided as large cannulae were not used. Willcox TW, Mitchell SJ, Gorman DF. 41: Perfusion. 1999 Nov;14(6):419-23. Vacuum assisted venous drainage (VAVD).

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Munster K, Andersen U, Mikkelsen J, Pettersson G. University of Copenhagen and Hamlet Private Hospital. Poor venous drainage is a common problem in cardiac surgery, causing trouble for the surgeon and adverse effects to the patient. Smaller incisions for minimally invasive cardiac surgery require smaller venous catheters. In this study the function, safety and possible benefits of a system for vacuum assisted venous drainage has been tested experimentally and applied clinically. A vacuum regulator ('The Hamlet box') and safety procedures were developed. The system was characterized in vitro in regard to the relationship between vacuum, catheter size, and blood temperature and flow. The clinical study included 54 adult patients, coronary artery bypass graft surgery and valve operations. Venous cannulation was bi-caval with two 24 Fr catheters. All the perfusions were essentially event free, and the system was easy to manage and regulate. Venous drainage was totally adequate, irrespective of the position of the heart, and less fluid was added during the perfusions (a median of 250 ml/patient compared to a median of 1000 ml/patient in the control group). There has been no evidence of increased haemolysis or other adverse effects. All patients were hospital survivors and had uneventful postoperative courses. Vacuum assisted venous drainage is now used routinely, and further studies are under way to develop the system and clarify the physiological effects. 42: Ann Thorac Surg. 1999 Oct;68(4):1285-9. Venous air in the bypass circuit: a source of arterial line emboli exacerbated by vacuum-assisted drainage.

Cardiothoracic Surgical Unit, Green Lane Hospital, Auckland, New Zealand. timw@ahsl.co.nz BACKGROUND: Arterial emboli cause neurocognitive deficits in cardiac surgical patients. Carotid artery emboli, detected ultrasonically, have been observed after venous air entrainment into the cardiopulmonary bypass circuit. We investigated in vitro the extent to which venous air affected emboli detected in the arterial line downstream from a 40-microm filter. METHODS: Using salvaged clinical cardiopulmonary bypass circuits, fixed volumes of air were introduced into the venous return line at unrestricted rates and at fixed rates using gravity venous drainage and vacuumassisted venous drainage. Emboli counts were recorded distal to the arterial line filter using a 2-MHz pulsedwave Doppler monitor. Emboli counts were similarly re-

Literature Abstracts
corded after the introduction of carbon dioxide into the venous return line instead of air. RESULTS: The number of emboli rose with increasing volumes of entrained venous air (p < 0.001), and there was an almost tenfold increase with vacuumassisted venous drainage (p <0.0001) compared with gravity venous drainage. Venous air was entrained at a significantly faster rate under vacuum-assisted venous drainage (p < 0.0001). When the entrainment rate of venous air was fixed, the difference in emboli numbers recorded for gravity and assisted venous drainage was not significant. There was a significant reduction in arterial line emboli when carbon dioxide rather than air was entrained under both vacuum-assisted and gravity drainage (p < 0.001). CONCLUSIONS: Entrained venous air during cardiopulmonary bypass is a potential hazard, particularly during vacuum-assisted venous drainage. Every effort should be made to avoid venous air entrainment. 43: J Extra Corpor Technol. 1998 Dec;30(4):184-9. Experimental use of an ultra-low prime neonatal cardiopulmonary bypass circuit utilizing vacuum-assisted venous drainage. Darling E, Kaemmer D, Lawson S, Smigla G, Collins K, Shearer I, Jaggers J. Perfusion Services, Duke University Medical Center, Durham, North Carolina, USA. In adult cardiopulmonary bypass surgery, vacuum assisted venous drainage has become a popular technique to augment venous return to the bypass circuit. The application of this technique in neonatal cardiopulmonary bypass surgery could be beneficial to the further miniaturization of neonatal circuitry by coupling radical repositioning of the oxygenator and pump console with decreasing line length. This report communicates the use of an investigational, vacuum assisted venous drainage neonatal circuit that is positioned at patient level utilizing a modified pump console with elevated double head twin roller pumps. The circuit, including the oxygenator, arterial line, venous line, raceway tubing, and a functional level in the venous reservoir has a priming volume of 107 ml. Initial bench and animal tests have demonstrated that this technique may be clinically feasible in CPB applications. With vacuum assisted venous drainage, the goal of asanguineous neonatal cardiac surgery could become a reality. Safety issues must be adequately addressed to ensure that this technique does not impose unacceptable risks. 44: J Extra Corpor Technol. 1998 Dec;30(4):160-5. Assisted venous drainage, venous air, and gaseous microemboli transmission into the arterial line: an in-vitro study. Rider SP, Simon LV, Rice BJ, Poulton CC. University Hospital Inc., Cincinnati, Ohio.

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The objective of this study was to examine the interaction of cardiopulmonary bypass venous air with assisted venous drainage, focusing on its production of gaseous microemboli in the arterial line. An in-vitro recirculating cardiopulmonary bypass circuit containing fresh whole bovine blood was monitored with a pulsed-doppler microbubble detector. Air of specific amounts was injected into the venous line and gaseous microemboli counts were obtained distal to the arterial filter. Data was recorded for unassisted drainage, vacuum-assisted drainage, and centrifugal pump-assisted drainage. Centrifugal pump-assisted drainage produced over 300 microbubbles in one minute distal to the arterial filter when venous air was introduced into the circuit. Of these, 220 were greater than 80 microns in size. Vacuumassisted drainage produced no microbubbles when the same amount of venous air was introduced into the circuit. However, vacuum-assisted drainage did produce some microbubbles in the arterial line when a stopcock was left open on the venous line for 30 seconds. Unassisted drainage produced no microbubbles at all levels of venous air entrainment. Air becomes entrained in the venous line from a variety of sources. In a typical gravity-drained situation, the air remains whole and is dissipated in the venous reservoir by buoyancy and filtration. In an assisted-drainage situation, the air is subjected to additional forces. The air is subjected to a greater degree of negative pressure and, with centrifugal pump assisted drainage, is subjected to kinetic energy imparted by the cones or vanes of the pump. The kinetic energy from the centrifugal pump appears to break the air into small bubbles which become suspended in the blood, passing through the reservoir, oxygenator, and arterial filter. In a clinical setting, these bubbles would be passed into a patient's arterial system. 45: Perfusion. 1999 Sep;14(5):389-96. Mini-circuit cardiopulmonary bypass with vacuum assisted venous drainage: feasibility of an asanguineous prime in the neonate. Lau CL, Posther KE, Stephenson GR, Lodge A, Lawson JH, Darling EM, Davis RD Jr, Ungerleider RM, Jaggers J. Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA. cllau@acpub.duke.edu Conventional cardiopulmonary bypass (CPB) in neonates results in increased transfusion requirements and hemodilution. There has been little advancement in CPB for the neonatal population. There is evidence that increased priming volumes and blood product transfusion enhances inflammatory response to CPB and increases myocardial and pulmonary dysfunction. We

Literature Abstracts
have devised a miniaturized CPB circuit that utilizes vacuum-assisted venous drainage (VAVD) in an effort to decrease priming volume and avoid transfusion requirements. The purpose of this study was to evaluate the safety and efficacy of this miniaturized CPB system and determine the feasibility of an asanguineous prime. Ten 1-week-old piglets were randomized to five mini- and five conventional CPB pump circuits. Subjects were supported with CPB at 100 ml/kg/min, cooled to 28 degrees C, exposed to 10 min aortic crossclamp with cardioplegic arrest, rewarmed to 37 degrees C, weaned from bypass, and subjected to modified-ultrafiltration (MUF) for approximately 10 min. This method was chosen to simulate a situation with all the elements of clinical CPB. Blood transfusion trigger was a hematocrit <15 on CPB. Serum samples were obtained pre-CPB, at 15 min of CPB onset, immediately post-CPB completion, and immediately post-MUF. Indices of hemolysis (SGOT, LDH), production of inflammatory mediators (interleukin (IL)-8, tumor necrosis factor-alpha (TNFalpha)), and physiologic parameters of inflammation were measured. The overall blood requirement was significantly less in the mini-circuit compared to conventional CPB (47.0+/-5.8 ml vs 314.2+/-31.6 ml; p < 0.0001). The only significant blood requirement in the mini-circuit was to replace the volume removed for samples. During the study, mean arterial pressure (MAP) (p = 0.004), static pulmonary compliance (p = 0.04), platelets (p = 0.0003), and white blood cells (p = 0.003) significantly decreased across the groups. Lung water content (p = 0.02), TNFalpha levels (p = 0.05), and SGOT (p = 0.009) increased significantly during the study, across the groups. Among all parameters tested, except for blood requirement and hematocrit post-CPB, there were no significant differences between the two circuits. VAVD makes asanguineous prime in neonates feasible. When used in this study to miniaturize a conventional-CPB circuit, VAVD with a reconfigured neonatal CPB console and circuit resulted in no detrimental effects, and allowed for markedly decreased priming volumes and blood transfusion requirements.

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