CARDIOPULMONARY BY-PASS

Dr. Md. Rezwanul Hoque

MBBS,MS,FCPS, FRCSG, FRCS Ed

Associate Professor( Cardiac Surgery) BSMMU, Dhaka Bangladesh .

DEFINITION:

CPB is the process by which the

pumping action of the heart & the gas

exchange function of the lung are

replaced temporarily by a mechanical

device -the pump oxygenator- attached

to the patients vascular system.

HISTORICAL BACKGROUND

Experiment on hypothermia with TCA & hypothermia with CPB went on parallel. Gibbon (1939) demonstrated support of circulation using pump oxygenator. Bigelow(1953), Lewis and Taufic(1953), Swan used TCA by surface cooling for intracardiac repair. Gibbon ( 1953) repaired ASD using CPB. Lillehi(1954) used controlled cross-circulation based on Azygos flow principle and one parent as oxygenator for cardiac defect correction. Sealy, Brow & Young(1958) combined TCA with CPB(core cooling & rewarming)

TYPES OF CPB:
Total

CPB-Systemic venous return diverted completely to pump oxygenator, then to arterial circulation, pts own cardiac & pulmonary function remain completely suspended. Partial CPB-Pts own heart & lungs participate and are being assisted by pump-oxygenetor.

TYPES OF CPB
Veno-Arterial Total Partial (e.g. perfusion of lower half of the body) Arterial-Arterial with pump Omit oxygenator Omit Heparin( heparin bonded tubing) Arterial-Arterial without pump( Heparin bonded tubing) Thoracic aneurysm operation Aortic transection operation

USES OF PARTIAL CPB:

In conventional CPB before application & after release of aortic

cross clamp.

Femoro-Femoral bypass- Total/ Partial Used in descending thoracic/ thoraco-abdominal operation for spinal cord protection .

Rapid warming of patient with hypothermic cardiac arrest maintaining CPB support

LA-Femoral bypass( Oxygenator omitted) used in descending thoracic & thoraco- abdominal aortic operation.

CONTD.
LVAD

, RVAD , BVAD use centrifugal pump to support the circulation bypassing sick ventricle. ( LVAD : LA PUMP AORTA . )

ECMO:

Veno-Arterial for bypass support of heart & lungs. RA/JV Pump Oxygenator RCCA

Veno- Venous ( IJV/ SVC Pump Oxygenator FV/ IVC RV lung LV ).

CONTD.
Veno-Venous by pass- vascular isolation for difficult IVC procedure Anhepatic phase of liver transplant Resection of renal & adrenal tumor with caval involvement Repair of traumatic injury to retrohepatic IVC IMV+ FV PumpRA or Axillary vein ** Rt. Renal tumor involving intracardiac IVC or RA needs total CPB and TCA

CPB CIRCUIT

COMPONENTS & CIRCUITRY OF PUMP

OXYGENATOR.

Arterial Pump :

A. Roller pump Non - Pulsatile mode . Flow proportional to ID of boot tube & RPM .

Partially occlusive Haemolysis more due to more stress Flow independent of downstream resistance ( Arterial line pressure if more than 300 mm Hg, line disruption/ cavitation may occur). Can produce pulsatile flow e.g. 80/min to maintain body physiology.

Pulsatile mode

COMPONENTS & CIRCUITRY OF PUMP

OXYGENATOR

B. Centrifugal Pump :

Incorporates impeller with vanes rotated by electric motor within a housing Flow generated by vortexing blood by impeller, blood enters central low pressure zones, exit through housing outer perimeter by centrifugal force Non-occlusive Flow depends on upstream/downstream resistance ( stops at 500mm Hg) Less haemolysis Non-pulsatile Used for long bypass e.g. > 6 hours

CENTRIFUGAL PUMP

HEART-LUNG MACHINE

SCHEMA OF CPB

COMPONENTS & CIRCUITRY OF PUMP

OXYGENATOR

C. Cardioplegia delivery pump.

D. Cardiotomy Sucker pump 2 in number, may be used as vent sucker.

COMPONENTS & CIRCUITRY OF PUMP

OXYGENATOR

E . Heat- Exchanger Heating- cooling machine is connected by inch water lines to inlet and outlet ports on the heat exchanger. Heat exchanger water flow is started and checked for leaks for the water compartment to the blood compartment. Oxygenator is discarded if water is present in the blood compartment.

EFFECT OF THERMAL CHANGE ON

METABOLISM

Vant Hoffs Law :

Q10 :

The logarithm of a chemical reaction is directly proportional to temperature.

Temperature change of 10c changes metabolic rate by 50% (Q10=2)

During

/ min. But during rewarming , temperature rise should be 1c / 5 min.

hypothermia , temperature fall should be1c

PRINCIPLE OF THERMAL MANIPULATION

27c profoundly decreases ischemic and reperfusion myocardial injury, further reduction is less advantageous. A temperature gradient of less than 10c between arterial & venous blood should be maintained, otherwise gas bubble may come out Water temperature should not exceed 42c,mixed-blood temperature should be less than 39.5c during rewarming During cooling water temperature should not be less than 5c, as it should not be less than 15c in case of mixed arterial blood.

Reduction of myocardial temperature from 37c to

WARM HEART SURGERY

Continuous cardioplegic perfusion of heart at 37c

reduces oxygen consumption by 90%, so further cooling of heart is unnecessary.

Using

this principle, operation can be safely done at 32c to 34c even at 37c.

TOTAL CIRCULATORY ARREST

More than 60 minutes of profoundly hypothermic (<20c) TCA produces some brain damage

whereas duration below 45 minutes is quite safe

TCA

is done at 18c to 20c, below 15c causes brain damage.

COMPONENTS & CIRCUITRY OF PUMP

OXYGENATOR

F. Venous reservoir

Venous reservoir bag:

PVC made, closed system, high safety profile as venous occlusion stops pump making alarming sound but air evacuation and volume management are difficult, drainage is bad and needs separate cardiotomy reservoir

Hard-shell venous reservoir:

Open system to air, cardiotomy reservoir built-in/separate, greater volume capacity, emptying of heart better, air handling easy but do not make alarming sound on emptying

HARD-SHELL VENOUS RESERVOIR

COMPONENTS & CIRCUITRY OF PUMP OXYGENATOR

G. Oygenators
Animal/ human lungs are used as oxygenator in controlled cross-circulation, in heart-lung pack oxygenators are artificially made. Two types:

Bubble oxygenator
Venous inlet heat exchanger( gas exchange, oxygen bubbling) defoamer arterial reservoir pump arterial line

Membrane oxygenator
Venous reservoir pump heat exchanger oxygenator filter arterial line

MEMBRANE OXYGENATOR
Rolled flat plate membrane Silicone made, long term use in ECMO e.g. Avecor Flat plate membrane Polypropylene made e.g. Cobe, CML Hollow fibre membrane Polypropylene made, blood flow outside & gas flow inside is better than vice versa e.g. Affinity NT, Quantum ICVR etc.
Each oxygenator has its own rate of flow (LPM), prime volume (ml), surface area Sq. m, Oxygen transfer (ml/min@LPM

CIRCUITS:
A circuit consist of all disposable elements used on heart-Lung machine.

Tubing ID 1/4 inch 3/8 inch

ml/ft. 09.65 ml 21.71 ml 38.61 ml 48.00 ml

Tubing volume

1/2 inch 5/8 inch

TUBING SIZE IN ADULT

Line Venous line Arterial pump line Boot tubing Arterial outlet line Sucker & vent line Cardiotomy line( connects CR to VR) Quick prime line Gas line( connects gas flow system, O2/air blender) to oxygenator ID (inch) 1/2 3/8 1/2 3/8 1/4 3/8 3/8 or 1/4 1/4

MANIFOLD SYSTEM
Three or four stop cock with tubing to connect arterial & venous sampling port.

Manifold system must be kept closed when not on bypass and prior to coming off bypass.

FILTERS:
Used in extracorporeal circuit for removal of microbubbles, microparticles & made of glass wool , dacron wool or polyurethane foam.

Blood filter:

Arterial line filter( 20-40 micron), priming volume 150-250ml Cardiotomy filter. Filters for banked blood

Non-blood filters

Pre-bypass filters- 5 micron Gas filters- 0.2 micron

Cardioplegia filters-0.2 micron ( Crystalloid CP only)

Blood CP filters- for leukocyte depletion

FILTERS

FILTERS ( CONTD)
Screen

filters- Filtration depends on pore filters- Glass wool, Dacron wool or

size, made of mesh material ( Dacron)

Depth

polyurethane foam through which blood

must pass.
Combination

of two.

ARTERIAL CANNULA
Size of the cannula is selected by evaluating the flow and pressure drop chart. The accepted limit of pressure drop ( difference between pressure entering the cannula and that leaving) is 100mm Hg. Arterial cannula may be straight, curved-tip, metal or PVC-tipped, and may be for femoral cannulation, high arch cannulation etc. Problems of arterial cannulation may be injury, dissection, air or atheromatous embolism, accidental selective cannulation, aneurysm formation etc.

ARTERIAL CANNULA

VENOUS CANNULA
Drainage may be by gravity or vacuum assisted venous drainage( VAVD) Single stage- separate SVC & IVC cannula Two stage- IVC & RA drainage by one cannula Thin right angled metal cannula- for selective SVC/ IVC cannulation Problems of venous cannulation include injury, air locking, poor drainage, flooding of operation field, problems with PLSVC, post-operative bleeding

VENOUS CANNULA

CANNULA( CONTD)
Cardioplegia cannula

Aortic root cannula Selective coronary cannula Retrograde cannula- automatic or manual balloon inflation

Vent cannula

Aortic root vent LV vent- through RSPV, RIPV, IAS, LV apex PA vent

CARDIOPLEGIC CANNULA

PURSE STRING & CANNULATION SITE

ARTERIAL CANNULA FLOW CHART: PRESSURE GRADIENT( MM HG)

Size in French scale

Flow ( L/ Min)

10 12

14 16 18 20 22 24

0.5 60 40 25

1.0 175 100 60 25 20

1.5 350 225 140 60 40 25 25

2.0
325

2.5

3.0

3.5

4.0

240 90 60 40 40 40

350 150 80 60 50 50

200 120

260 150

200

80 60 60

100 75 70

120 90 80

VENOUS CANNULAS FOR VARIOUS FLOWS

Total flow ( L/Min)
< 0.9 0.9-1.75 0.9-1.2 1.2-1.6 1.6-1.75 1.7-2.2 2.2-2.8 2.8-3.2 4/16 5/16 5/16 28Fr 4/16 4/16 5/16

Cannula size
Pacifico angled metal
Single tygon 3/16 4/16 Single USCI 20Fr 24Fr 3/16 20Fr 22Fr 24Fr 28Fr 30Fr 32Fr 20Fr 20Fr 24Fr 24Fr 28Fr 28Fr 24Fr 24Fr 24Fr 28Fr 28Fr 28Fr Two Tygon Two USCI 16Fr SVC 16Fr IVC 20Fr

3.2-3.7
3.7

6/16
8/16

5/16
6/16

34Fr
36Fr

28Fr
32Fr

32Fr
32Fr

SELECTION OF ARTERIAL CANNULA :

Size selected by evaluating the flow & Pr. drop chart. Pr. Drop means difference between pressure entering the cannula & that leaving the cannula, accepted limit of Pr. Drop is 100 mm Hg . @ BSA x 2 . 5 = Full flow ( at 37 degree Centigrade) @ BSA X 2 .2 = Flow at 34 degree. @ BSA X 1.8 = Flow at 28 degree. BSA= Ht( cm) x Wt( kg) / 3600

PRIME :

To deair the oxygenator & partially fill up the circuitry, crystalloid or colloid is taken as prime volume, just before starting CPB.

Haemic Priming.
Non-Haemic Priming. e.g. Polycythemia, profound
hypothermia with TCA.

Priming volume -20-30 ml/ Kg BW.

Includes oxygenator priming volume+ filter volume+ tubing volume

Cont.

COMPOSITION OF PRIMING VOLUME

Ringers solution CPD blood Mannitol 20% NaHCO3( 8.4%) Heparin for circuitry Antibiotics Heparin for blood 6unit/ ml of blood added 1000-1500ml 1-3 unit( Hct kept at 0.25-0.30) 200-300ml 10ml/500ml CPD blood 5000 unit

CaCl2( added last)

Albumin 25%

10ml/ unit of CPD blood

To preserve COP

HAEMATOCRIT MANAGEMENT DURING CPB

Normal Hct - 0.4-0.5 at 37 degree ( Hct viscosity) During CPB acceptable Hct- 0.25-0.30

** Mitochondrial PO2 0.05-1 mm Hg, Intracellular PO2 5mm Hg, PVO2 40 mm Hg( SVO2 75%), PAO2 90-104 mmHg ( SAO2- 98%)

Pt. blood volume = body wt. In Kg X factor (80) = 60 x 80 =4800 ml.

Red cell volume = Pts B.V. x Hct .= 4800 x .36= 1728 ml.
Total circulatory volume = BV + Prime vol.=4800 + 1200 =6000ml. Pts Hct = RBC Volume/TCV = 1728 /6000 =0.28 = 28 % .

HEPARINISATION:UAB PROTOCOL

Baseline ACT

Heparin administered at a dose 300 u/kg

ACT checked prior to CPB to ensure> 480 sec On CPB, ACT is checked every 30 minutes, Heparin added (100 units/ kg) as required. Reversal of heparin 1 .5 mg protamine / 100 unit initial heparin dose. For infants, initial dose and heparin doses are added to pump prime ACT checked, if prolonged ACT tested with heparinase, more protamine added

HYPOTHERMIA :

Use of hypothermia in association with CPB which allow low perfusion flow rate because of reduced oxygen consumption.

Type

Temp ( degree centigrade)

TCA (min) at temp

Mild

37-32

10min at 32

Moderate

31-28

10-15min at 28
16-45 min at 18

Deep

28-18

Classification

Profound

18-0

46-60 min at <18

GAS/BLOOD FLOW RATE AT HYPOTHERMIA: BLOOD FLOW

MUST BE KEPT GREATER THAN BLOOD FLOW RATE, OTHERWISE GAS EMBOLISM MAY OCCUR

Temp ( degree centigrade)

Cardiac index

FIO2

Gas/Blood flow ratio

37
34

2.4 L
2.2 L

.80
.70

1:1
.8:1

30
28

2.0 L
1.8 L

.65
.60

.7:1
.6:1

22
18-20

1.6 L
1.0 L

.50
-

.5:1
-

0.5L/min/ Sq.M is adequate for 30-60 minutes

ACCEPTABLE DATA DURING CPB :

PH-- 7.4 .

Po2--- 100 - 250 mm Hg.

P co2--40 mmHg. Glucose concentration of the prime < 350mg/dl

Perfusion Pr.-- 50-60 mm Hg.( If < 40 mm Hg

cerebral damage, If > 100 mm Hg -SVR raised so, microcirculation impaired.

Perfusion flow 2.2-2.5 l/m/m sq . are adequate. hypothermia allows lesser flow rate.

PRE BYPASS CHECK LIST

Gas lines connected Exhaust cap removed O2 source operable Water lines connected Water heater-cooler operable & warming Oxygenator checked for water leak before priming Arterial occlusion set on roller head pumps Arterial filter primed Pressure transducer zeroed Stopcocks closed properly Luer connection tight Pump flow rates set

Sucker and vent in proper direction in housing Vent valve in proper direction Cardioplegia present with proper drug added Drugs in prime Bubble detector operable Level detector operable Back-up power present Temperature probes connected BSA & flows calculated

CHECK LIST DURING BYPASS

O2 flowing Arterial line pressure is not excessive Pump flow correct Patients arterial pressure acceptable Temperature of waterheater correct Coagulation status acceptable ACT> 480 secs

Bubble detector on Level detector on Urine in Foleys emptied, monitored during case Manifolds open Required drugs given

MONITORING DURING BYPASS

Anaesthesiologist

ABG PA pressure, PAWP, MVO2 BP PETCO2

Surgeon Observes distension of PA Detects failure of venous drainage Manually confirms arterial pressure Observes aorta for dissection

Perfusionist SaO2 SVO2 Hb% Blood level in oxygenator reservoirs Coagulation status S. Electrolytes ABG

MYOCARDIAL PROTECTION
Mild to moderate hypothermia with cardioplegic arrest of heart under CPB

Continuous or intermittent antegrade cardioplegia with

normothermic CPB in warm heart surgery . Profound hypothermia ( <20degree centigrade ) with TCA Intermittent cross clamping with CPB, 2 minutes release after every 12 minutes X-clamp in fibrillating heart, no CP Fibrillating heart with CPB, no X-clamp Empty beating heart with CPB, no X-clamp

Inflow occlusion for short procedure e.g. PA valvutomy

Beating heart surgery (CABG)

CARDIOPLEGIA
Regime-1
DBL (20 ml) 16mmol K+ 16mmol Mg++ + 2 ampoules KCl (20 ml) 40mmol K+ Each ml contains 56/40= 1.40 mmol K+/ml 6ml purge gives 6x1.40= 150ml/hour (2.50ml /min) for 2 min, 5x1.40= Blood contain
Total

8.40mmol K+ 7.00mmol K+ 4.50 mmol K+

20.00mmol/L

CARDIOPLEGIA
Regime-2
3.5 ampoule KCl+ 1.5 ampoule MgSO4= 35ml+7.5ml=42.5ml K+ concentration, 70/42.5= 1.64mmol/ml 5.50ml purge, 5.50X1.64= 9.02mmol K+ 150ml/hr, 2.5ml/min, for 2 min, 5X1.64= 8.20mmol K+ Blood contains 4.50mmol K+
Total 21.72mmol K+

CARDIOPLEGIA
Routes of administration

Temperature

Antegrade- aortic route/ selective Retrograde- coronary sinus and/or simultaneous) Combined Through anastomosed vein graft (alternating

Cold CP (4 degree C) Warm blood CP( Perfusate temp) Warm induction( ante or retrograde) warm reperfusion( low K+ plus substrate) Blood CP & Non cardioplegic cold blood reperfusion

Composition

Antegrade CP
Given at 70mm Hg pressure, 200ml/min, 1520ml/kg BW, at 20 minutes interval

Crystalloid CP
Blood CP High K+(>20mmol K+/L) for induction Low K+(<10 mmol K+?L) for reperfusion

Retrograde CP
Given at 25-40mm Hg pressure, 100-200ml/min,1520ml/kg BW

Timing

CP in children
500XBSA / 1.5

Intermittent Continuous

Antegrade CP is less effective in severe multivessel disease and acute coronary occlusion

CP- COMPOSITION

K+ 15-30mmol/L Ca++ 0.5-1.0mmol/L Na+ 100-140mmol/L PH 7.6 Osmolality 380mosm Glucose>100mg/dl Red blood cell Magnesium Aspartame, Glutamate, GTN, Procaine/ Lidocaine, energy enriching compound, BufferHCO3,TRIS,THAM,EDTA, Blood, albumin, mannitol etc.

Newer additives for reperfusion

Adenosine, lidoflazine, Myoflazine Free radical scavengers e.g. SOD catalase SOD with polyethylene glycol Desferoxamine Glutathione Ascorbic acid Tocopherol

ACID BASE MANAGEMENT ( CPB ):

Maintenance of physiological level of arterial Pco2 & Po2 ( 35-40 mm Hg & less than 200 mm Hg respectively ) ought to be the goal during CPB . All perfused tissues , O2 needed for cell metabolism & to remove CO2 ( produced by cell metabolism ) . Metabolic acidosis occur during CPB due to poor tissue perfusion if arterial flow is low. In metabolic acidosis , peripheral vasoconstriction may results. So, correction of acidosis & alkalosis is essential on the basis of blood gas report during CPB .

EFFECT OF HYPOTHERMIA ON ACID-BASE BALANCE- SOLUBILITY OF CO2,PH,PCO2

PH stat strategy

Alpha stat strategy

PH 7.4 and PCO2 40mm Hg should be maintained regardless of temperature.

PH is made alkaline, PCO2 is decreased at hypothermia

No CO2 is added Refers to the fraction of unprotonated imidazole group of histidine, this fraction stays constant as temperature decreases

PH is measured as if it is at 37 degree C, 5% CO2 is added to adjust PH to 7.4

WEANING :

Deairing of heart is done before removal of X-clamp Volume is added gradually Inflow of blood is increased Outflow of blood is decreased Arterial BP is optimised CVP, LA pressure is optimised Patient is made normothermic Heparin is neutralized by protamine Haemodynamic stability is ensured by inotropes/ vasodilator/ pressors Rhythm and contractility optimised by pharmacological means and pacing

PATHOPHYSIOLOGIC RESPONSE TO CPB

Catecholamine-Eph NE due to pulm. blood flow Cortisol Renin-angiotensinaldosterone T3 ANF Cytokines- IL1,IL6, IL8 Protease release Elastase

Partial coagulation activation. Compliment activation, mainly by alternate pathway Arachidonic acid activation . Fibrinolytic activation .

Kallikrein-bradykinin activation.

DAMAGING EFFECTS OF CPB :

Air embolism.

Myocardial depression &

Bleeding disorder .
Constrictive pericarditis . Infection. Microembolism . Mediastinal tamponade. Cholecystitis Intestinal ischemia/infarction
Cont.

LOS.

Neurological dysfunction . Pancreatitis . SIRS & MOF . Pulmonary & Vascular injury .

Post cardiotomy syndrome

ISCHEMIA/ REPERFUSION INJURY

Myocardial consequences of global ischemia

Reperfusion abnormalities

Cell depolarization Calcium loading ATP hydrolysis

Cell swelling Calcium loading High energy phosphate precursor loss Oxygen wasting Free radical injury Mitochondrial dysfunction

Acidosis
Potassium leakage Sodium loading Contracture