FIFTEEN YEARS PERFUSION EXPERIENCE WITH MINIMAL

INVASIVE EXTRACORPOREAL CIRCULATION:

WHAT LESSONS CAN WE LEARN?

2nd International Symposium on

Minimal Invasive Extracorporeal

Circulation Technologies

MiECT

ATHENS 9 – 11 June 2016

Hj. Jenni; B. Winkler; T. Carrel

University Hospital Bern

Switzerland

Agenda

• MiECC and CABG

• Challenges and solution proposals

• Cardiac index in MiECC perfusion

• Education → Medtronic Academia

• Conclusion

Berne experience

Totally MiECC cases since 2001:

• 6000 MiECC perfusions

Application range:

• CABG → all cases (incl. PFO-closure)

• Rewarming from accidental hypothermia

• Selected pediatric cases

• Aortic valve surgery

Modern systems

Requirements to modern perfusion systems

• Minimized artificial surface

• Minimized priming volume

• No blood – air contact

→ maximal biocompatibility

CABG

Perfusion specific requirements

• Maintenance of the circulation

• Cardioplegia administration

• Suction blood management

→ no opening of the heart chambers

→ no “vent-blood”

→ no additional perfusion (e.g. SACP)

MiECC and CABG

CABG requirements allows a maximal

reduction of components and tubing

Suction blood separation

and retransfusion in

emergency cases

Single shot cardioplegia

Bernese MiECC concept

MiECC in CABG

Measures:

Closed system:

- no blood-air contact

- reduced artificial surface

- reduced priming volume

Suction blood separation:

- reduced inflammatory response

Cardioplegia:

- low volume loading (100ml)

→ improved biocompatibility

Challenge: Air entry

Lessons learned

• Implementation of new generation

oxygenators into the MiECC system

• Additional air-elimination procedure

via suction reservoir and connector

position

• Venous bubble trap is not required:

→ additional artificial surface

integrated32 µm arterial filter

Challenge: Air entry

Air detection on the venous side

Connection to suction reservoir

→ vertical position of the connector

Suction reservoir under vacuum

Challenge: Venous collapsing

• Depending to volume status

• Depending to pump speed

• Intraoperative maneuver → luxation

• Cannula size and shape

2 MHz pulsed –wave transducer; Spencer Technologies;

Seattle;WA;USA

• Venous pre- and filling → Cave: RAP

• Vasoconstrictors

• Reduced pump speed → Tailored perfusion

• Patient adapted venous cannula

• P1-Monitoring and auto adaptive regulation

Challenge: Venous collapsing

Lessons learned

Challenge: Venous collapsing

Lesson learned

• Tailored perfusion

• Example:

- CABG (3x)

- Male; 170cm;80kg

- Calculated flow: 3.9 l/min

→ monitored flow reduction during

maximal luxation can avoid venous

collapsing

Calculated pumpflow

Height: 190cm

Weight: 90 kg

BSA: 2.2 m2

Calculated bloodflow cCPB (Index 2.4 l/m2/BSA):

5.2 l/min

Calculated bloodflow MiECC (Index 2.0 l/m2/BSA):

4.4 l/min

Artificial surface

Terumo FX 15:

Surface area:

1.5 (+0.14) = 1.64 m2

(incl.art filter; heat exchanger)

Blood flow range:

0.5 – 5.0 l/min

Terumo FX 25

Surface area:

2.5 (+0.2) = 2.70 m2

(incl.art.filter;heat exchanger)

Blood flow range:

0.5 – 7.0 l/min

Artificial surface

Terumo FX 15/FX25

• Membrane surface: 1.64 m2

• 2.7 m2 – 1.64 m2 = 1.06 m2

• ≈ 40% surface reduction

→ ≈ 35 m of 3/8“ - tubing

Education

Agenda

• Theoretical training:

- Perfusionist

- Anesthesiologist

- Surgeon

→ target audience

• “Hands on training”

• Practical part: Live surgery

Education

Theoretical training

• 3 presentations:

- Surgeon

- Anesthesiologist

- Perfusionist

• Theoretical MiECC specific

aspects

• Pitfalls and prevention

Education

Live surgery

• Practical demonstration of:

- Perfusion strategies

- Management of anesthesia

- Surgical tips and tricks

• Pitfalls and solutions:

- Cardioplegia

- Volume management

- Coronary blood flow

- Suction events

Education

Simulation and trouble shooting

• Relaxed ambiance

• How to manage:

- Air elimination

- Massive bleeding

• Generally tips and tricks

Conclusion

The CABG procedure offers a maximal reduction of the

MiECC-system

The implementation of new generation oxygenators offers

additional safety

Patient adapted perfusion can help to avoid suction events and

allows a reduction of the artificial surface

For maximal safety: Interdisciplinary education is essential