Pediatric extracorporeal life Pediatric extracorporeal life support systems and support systems and

Pediatric cardiopulmonaryPediatric cardiopulmonaryperfusion systems: Now and perfusion systems: Now and

futurefuture

Asist.Prof.Dr. Tolga KURTAsist.Prof.Dr. Tolga KURTCanakkale Onsekiz Mart UniversityCanakkale Onsekiz Mart University

TurkeyTurkey

International Conference and Exhibition on International Conference and Exhibition on Pediatric CardiologyPediatric Cardiology

August 25-27, 2015 ValenciaAugust 25-27, 2015 Valencia

Background - HistoryBackground - History

CPBECMO‐ECLSVADTAH

The first heart-lung machine (HLM) which The first heart-lung machine (HLM) which was made by Gibbonwas made by Gibbon

CPBECMO‐ECLS

VADTAH

The new HLM machinesThe new HLM machines

One of the first machines and One of the first machines and surgical teamsurgical team

Now Now

Differances between pediatric and Differances between pediatric and adult adult Cardiopulmonary PerfusionPediatric organ sytems are not developed Pediatric organ sytems are not developed sufficiently as adults.sufficiently as adults.

The size of the organs are smaller than the The size of the organs are smaller than the adultsadults

The rate of metabolism is higher than adults The rate of metabolism is higher than adults ↔↔ higher perfusion rate is needed.higher perfusion rate is needed.

The frequent need of intracardiac accessThe frequent need of intracardiac access

Presence of abnormal anatomy and physiologyPresence of abnormal anatomy and physiology

Differances between Differances between pediatricpediatric and and adultadult cardiopulmonary

bypass (CPB) proceduresExtreme hypothermia, hemodilution and Extreme hypothermia, hemodilution and perfusion flow rate valuesperfusion flow rate valuesPathological anatomy Pathological anatomy operation technical technical changeschangesCPB circuit extremely large compared to body CPB circuit extremely large compared to body massmass index indexThe prime volume is more than the total blood of The prime volume is more than the total blood of newborns and infants.newborns and infants.Large body mass index differences observed in Large body mass index differences observed in the casesthe casesselection of appropriate materials selection of appropriate materials required in each case.required in each case.

Pediatric CPB Complications Pediatric CPB Complications ↑↑↑↑↑

We must lower the prime volume ↓We must lower the surface area which the

blood contacts. ↓We must reduce the size of the circuit

components ↓

Prime VolumePrime Volume

Adults Adults 25-30 % Of the total blood 25-30 % Of the total blood volumevolume

Neonates Neonates 2-3 times Of the total blood 2-3 times Of the total blood volumevolume

To prevent excessive hemodilution To prevent excessive hemodilution Donor blood can be add to prime volumeDonor blood can be add to prime volume

Sanguineous prime volumeSanguineous prime volume

Blood-borne infections

Reinforcement of inflammatory reaction

Transfusion-induced acute lung injury

Pulmonary hypertension

The organ perfusion disorders due to rheological properties Low cardiac index

Our TargetOur Target : :

Lower prime oxygenator volumeLower prime oxygenator volumeReducing the size of the venous line Reducing the size of the venous line Reducing the size of the circuitReducing the size of the circuitArterial line filterArterial line filterVenous Reservoir LevelVenous Reservoir Level

↓ ↓ ↓ ↓

The circuit prime volume reduction The circuit prime volume reduction and and non non sanguineous primesanguineous prime

volumevolume

ALF:Arterial line filterMcRobb CM, Mejak BL, Ellis WC, Lawson DS, Twite MD.

Recent Advances in PediatricCardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth .

2014;18(2):153–60.

Pediatric CPB pumpsPediatric CPB pumps

Roller Pumps

Centrifugal Pumps

Roller Pumps

+++ With small diametered lines, the prime volume is low+++ Sensitive flow control even at low flow rates--- Hemolysis or damage to the other formed elements of the blood--- Roller pump induced tubing tear of polyvinylchloride and silicone rubber tubing--- Inability to provide appropriate position The new generation heart lung machine can be given the required position.

Centrifugal Pumps

+++ More mobile

+++ Less hemolysis or damage to the other formed elements of the blood

+++ Reducing the flow line to prevent the high pressure in arterial line obstructions

--- High prime volume

--- Insufficient sensitivity at low flow rates

New generation centrifugal pumpsNew generation centrifugal pumpsPrime volume

(ml)

Max FlowMax Flow

(L/min)(L/min)Connector

Medos Deltastream DP3Medos Deltastream DP3 1616 88 3/8”

Medos s.pump 1717 88 3/8”

Levitronix CentriMag 3131 1010 3/8”

Maquet ROTAFLOW 3232 1010 3/8”

Medtronic Affinity CP 4040 1010 3/8”

Terumo CAPIOX SP 4545 88 3/8”

Medtronic BP‐50 Bio‐Pump 4848 1.51.5 1/4”

Sarns disposable centrifugal pump 4848 1010 3/8”

Sorin RevOlution 5252 88 3/8”

Pediatric OxygenatorsPediatric Oxygenators

Structure Structure Holow fiber Holow fiberGas exchange surface Gas exchange surface porous polypropylene porous polypropylene

Gases transmit from the pores through blood

Erythrocytes and plasma does not transmit !!Erythrocytes and plasma does not transmit !!

Pediatric OxygenatorsPediatric Oxygenators Wide temperature range (10 °C - 40 °C)Wide temperature range (10 °C - 40 °C)

Wide flow range (0 - 200 ml / kg / min)Wide flow range (0 - 200 ml / kg / min)Htc wide range (15% - 40%)Htc wide range (15% - 40%)Wide range of line pressureWide range of line pressure

Wide gas flow rangeWide gas flow range

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ Despite its small surface area, effective Despite its small surface area, effective

gas exchange, even at high flow.gas exchange, even at high flow.

Pediatric OxygenatorsPediatric Oxygenators Priming volume (ml)

Surface area Surface area ((m2))

Max FlowMax Flow

(L/min)(L/min)

Sorin D100 Kids 3131 0.220.22 0.70.7

Maquet QUADROX‐i Neonatal 3838 0.380.38 1.51.5Terumo CAPIOX BabyRx 4343 0.500.50 1.51.5Medtronic Affinity Pixie 4848 0.670.67 22Medos Hilite 1000 5757 0.390.39 11Sorin Lilliput I 6060 0.340.34 0.80.8Maquet QUADROX‐i Pediatric 8181 0.800.80 2.82.8Sorin D101 Kids 8787 0.610.61 2.52.5Medos Hilite 2800 9898 0.800.80 2.82.8MedtronicMinimax Plus 149149 0.800.80 2.32.3

Pediatric Tubing SetsPediatric Tubing Sets

Tubing sets Tubing sets 75 % of the prime volume 75 % of the prime volume The most important step in reducing the tubing The most important step in reducing the tubing set volume set volume Reducing the length and diameter Reducing the length and diameter of the tubing set:of the tubing set:------Approximation of the pump to the patient ------Approximation of the pump to the patient about 29% reduction in the volume of primeabout 29% reduction in the volume of primeTubing set diameter reduction Tubing set diameter reduction the resistance the resistance to flow increase to flow increase assisted venous drainage assisted venous drainageShortening of the tubing set Shortening of the tubing set decrease of the decrease of the resistance resistance

Pediatric Arterial FiltersPediatric Arterial Filters

Disadvantages:Disadvantages:

--------High prime volume--------High prime volume

--------A large foreign surface--------A large foreign surface

--------The difficulty of removing the air bubbles--------The difficulty of removing the air bubbles

Pediatric Arterial FiltersPediatric Arterial Filters Priming volume (ml)

Max FlowMax Flow

(L/min)(L/min)Pore (Pore (µµm)m)

Sorin D130 Kids ALF 1616 0.70.7 4040

Sorin D131 Kids ALF 2828 2.52.5 4040

Medtronic Affinity Pixie ALF 3939 3.23.2 3030Terumo CAPIOX ALF AF02 4040 2.52.5 3232

Integrated productsIntegrated products

Only reducing the component sizeOnly reducing the component size insufficient to reduce prime volumeinsufficient to reduce prime volume

We need integrated component products We need integrated component products oxygenator + arterial filter oxygenator + arterial filter

Priming volume (ml)

Max FlowMax Flow

(L/min)(L/min)Pore (Pore (µµm)m)

Maquet QUADROX‐i NeonatalMaquet QUADROX‐i Neonatal 3838 1.51.5 3333Terumo CAPIOX FX05Terumo CAPIOX FX05 4343 1.51.5 3232Maquet QUADROX‐i PediatricMaquet QUADROX‐i Pediatric 8181 2.82.8 3333Terumo CAPIOX FX15Terumo CAPIOX FX15 144144 5.05.0 3232

Integrated productsIntegrated products

No need for an extra prime volume for the No need for an extra prime volume for the arterial filtersarterial filtersThe captured gas bubbles are transferred to the The captured gas bubbles are transferred to the oxygenator gas reservoir by the pressure oxygenator gas reservoir by the pressure difference.difference.Particulate emboli capture efficiency is similar to Particulate emboli capture efficiency is similar to standard filtersstandard filters

Gas emboli capture efficiency Gas emboli capture efficiency is higher than is higher than standard filterstandard filterss

Pediatric cardioplegiaPediatric cardioplegia

Standard blood cardioplegiaStandard blood cardioplegiaDel Nido cardioplegiaDel Nido cardioplegiaCrystalloid cardioplegiaCrystalloid cardioplegia

------St. Thomas solution------St. Thomas solution------------Custodiol (Histidine-Tryptophan-

Ketoglutarate)Microplegia

------Quest Biomedical MPS2 Myocardial ProtectionSystem (prime 7-35 mL)

Pediatric UltrafiltrationPediatric Ultrafiltration

It has a porous hollow fiber structuremade with It has a porous hollow fiber structuremade with polysulfone, molecules Weighting <50-65 kDa polysulfone, molecules Weighting <50-65 kDa can pass .can pass .

Aim:Aim:Reduction of EdemaReduction of EdemaRaising hematocrit valuesRaising hematocrit valuesRemoval of electrolyte (potassium)Removal of electrolyte (potassium)Removal of Inflammation mediators, lactate and Removal of Inflammation mediators, lactate and citratecitrate

Pediatric UltrafiltrationPediatric Ultrafiltration Prime(ml)Prime(ml)

Medivator Hemocor HPH Jr 88

Medivator Hemocor HPH Mini 1414

Maquet BC20 Plus 1717

Medos Hemofilter Pro 20 1717

Sorin Dideco DHFO.2 Hemoconcentrator 3030

Medivator Hemocor HPH 400 3434

Terumo CAPIOX Hemoconcentrator 3535

Medos Hemofilter Pro 60 5252

Maquet BC60 Plus 6565

ECMO‐ECLS(Extracorporeal Membrane Oxygenation - ExtraCorporeal Life Support)

The aim is to provide sufficient time and appropriate The aim is to provide sufficient time and appropriate environment for the restoration of myocardial and lung environment for the restoration of myocardial and lung damage.damage.

ECLS

----------ECMO

----ECCO2R (Extracorporeal carbon dioxide removal )

----VAD (ventricular assist device )

ECMO‐ECLS

ECMO PUMPS

Roller pumps are the most commonly used.Roller pumps are the most commonly used.

++++ ++++ InexpensiveInexpensive++++ Reliable++++ Reliable++++ Laminar flow++++ Laminar flow----- Hemolysis----- Hemolysis----- Spallation and tube rupture----- Spallation and tube ruptureSpallationSpallation : :

The sloughing off of plastic and silastic tubing particles into the lumens of The sloughing off of plastic and silastic tubing particles into the lumens of tubing through the erosive and fatiguing action of rollers in the pump head.tubing through the erosive and fatiguing action of rollers in the pump head.

Spallation and tube ruptureSpallation and tube rupture

ECMO PUMPS

To prevent excessively high and low pressure To prevent excessively high and low pressure formation formation continuous measurement of arterial continuous measurement of arterial and venous pressure lineand venous pressure line

Prime volume (mL)

Connector

Medtronic Bladder Reservoir R‐14 3535 1/4”

Medtronic Bladder Reservoir R‐38 3535 3/8”

ECMO PUMPS

Centrifugal Pumps:Centrifugal Pumps:

++++ Less traumatic to blood cells++++ Less traumatic to blood cells

------ Sensitive preload and afterload------ Sensitive preload and afterload

------ Insufficient flow due to the high ------ Insufficient flow due to the high internal resistance of the silicon internal resistance of the silicon membrane oxygenators.membrane oxygenators.

------ The risk of thrombosis in long-term ------ The risk of thrombosis in long-term use (5-7 days). use (5-7 days).

ECMO OxygenatorsECMO Oxygenators

Porous polypropylene hollow fiber Porous polypropylene hollow fiber oxygenatorsoxygenators In long-term use: wetting of In long-term use: wetting of the membrane structures, leakage of the membrane structures, leakage of plasma, dysfunction.plasma, dysfunction.For long-term usage For long-term usage non-porous silicon non-porous silicon membrane oxygenatorsmembrane oxygenatorsThere are no holes in the silicon There are no holes in the silicon membrane. Gases diffuse through the membrane. Gases diffuse through the blood from the siliconblood from the silicon

ECMO OxygenatorsECMO Oxygenators

Spiralcoiled structure Spiralcoiled structure high resistance to blood high resistance to blood flow flow blood oxygenator transition speed slows blood oxygenator transition speed slows down and increases gas transferdown and increases gas transfer

Internal heat exchanger available Internal heat exchanger available also adding also adding circuit heat exchanger unit circuit heat exchanger unit increase in the prime increase in the prime volume of the systemvolume of the system

Silicone membrane Silicone membrane oxygenatorsoxygenators

Prime volume

(mL)

Surface area Surface area ((m2))

Max FlowMax Flow

(L/min)(L/min)

Avecor/Medtronic 0800 100100 0.80.8 1.21.2

Avecor/Medtronic 1500 175175 1.51.5 1.81.8

ECMO OxygenatorsECMO Oxygenators

Polymethylpentene porous hollow fiber Polymethylpentene porous hollow fiber oxygenator:oxygenator:

+++++Long-term use (up to 2 weeks)+++++Long-term use (up to 2 weeks)No largely plasma leakageNo largely plasma leakage

+++++ Internal heat exchanger +++++ Internal heat exchanger No increase in prime volumeNo increase in prime volume

+++++ Centrifugal pump usage according to +++++ Centrifugal pump usage according to their low internal resistancetheir low internal resistance

ECMO OxygenatorsECMO Oxygenators

Polymethylpentene Polymethylpentene oxygenatoroxygenator

Prime volume (mL)

Surface Surface area area

((m2))

Max FlowMax Flow

(L/min)(L/min)

Medos Hilite 800LTMedos Hilite 800LT 5555 0.320.32 0.80.8

Eurosets ECMO NEW BORNEurosets ECMO NEW BORN 9090 0.690.69 1.51.5

Medos Hilite 2400LTMedos Hilite 2400LT 9595 0.650.65 2.42.4

Sorin EOS ECMOSorin EOS ECMO 150150 1.21.2 55

Maquet QUADROX‐iD ECMOMaquet QUADROX‐iD ECMO 250250 1.81.8 77

ECMO Heat ExchangersECMO Heat Exchangers

Newborn ECMO Newborn ECMO thermoregulation ability is thermoregulation ability is underdevelopedunderdeveloped

Prime volume (mL)

Max FlowMax Flow

(L/min)(L/min)

Gish Biomedical HE‐3 2020 22

Medtronic ECMOtherm II HE 5050 22

Gish Biomedical HE‐4 6060 22

ECMO Tubing SetsECMO Tubing Sets

DEHPDEHP in PVC tubes (di (2-ethylhexyl) phthalate) in PVC tubes (di (2-ethylhexyl) phthalate) infertility in long-term usage infertility in long-term usage

No abnormalities in clinical development for No abnormalities in clinical development for patientspatients

ECMO with the roller pump ECMO with the roller pump PVC tube line in PVC tube line in the pump head the pump head spallation and tube rupture spallation and tube rupture

Tygon S-65 HL tubes are more resistant to Tygon S-65 HL tubes are more resistant to spallation and tube rupture, they can be spallation and tube rupture, they can be preferred.preferred.

Pediatric circulatory supportPediatric circulatory support

Short-term (<30 days) assistance Short-term (<30 days) assistance ECMO, ECMO, centrifugal pump or roller pumpcentrifugal pump or roller pumpLong-term assistance Long-term assistance Ventricular assist Ventricular assist devices (VAD):devices (VAD):

Parakorporeal pneumatic pulsatile VADParakorporeal pneumatic pulsatile VADNewborns and infantsNewborns and infantsBerlin Heart, Berlin Heart,

Medos HIA VADMedos HIA VADAdolescentsAdolescentsThoratec VAD,

Heartmate VADAxial flow devicesAxial flow devices MicroMed/DeBakey VAD

Good luck to all of Good luck to all of our children, and our children, and Godspeed in now Godspeed in now and future.and future.

Thank You…Thank You…

ReferencesReferences1.Van Doorn C, Elliott M. Cardiopulmonary Bypass in Children with Congenital Heart Disease. In: Kay PH, Munsch CM, editors.Techniques in Extracorporeal Circulation. 4th ed. London: Arnold; 2004. p. 177–83.2.Giacomuzzi C, Brian M, Shen I. Pediatric Cardiopulmonary Bypass Overview: State of the Art and Future. In: Gravlee GP, Davis RF,Stammers AH, Ungerleider RM, editors. Cardiopulmonary Bypass: Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams &Wilkins; 2008. p. 686–700.3.Charette KA, Davies RR, Chen JM, Quaegebeur JM, Mosca RS. Pediatric Perfusion Techniques for Complex Congenital Cardiac Surgery.In: Mongero LB, Beck JR, editors. On Bypass: Advanced Perfusion Techniques. New Jersery: Humana Press Inc.; 2008. p. 29–58.4.McRobb CM, Mejak BL, Ellis WC, Lawson DS, Twite MD. Recent Advances in Pediatric Cardiopulmonary Bypass. Semin CardiothoracVasc Anesth. 2014;18(2):153–60.5.Chai PJ. Myocardial Protection and Preservation for Neonates and Infants. In: Gravlee GP, Davis RF, Stammers AH, Ungerleider RM,editors. Cardiopulmonary Bypass: Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 701–10.6.Turkoz R. Myocardial protection in pediatric cardiac surgery. Artif Organs. 2013;37(1):16–20.7.Kotani Y, Tweddell J, Gruber P, Pizarro C, Austin EH, Woods RK, et al. Current cardioplegia practice in pediatric cardiac surgery: aNorth American multiinstitutional survey. Ann Thorac Surg. 2013;96(3):923–9.8.Hickey EJ, Karamlou T, Ungerleider RM. Brain Injury Following Infant Cardiac Surgery and Neuroprotective Strategies. In: Gravlee GP,Davis RF, Stammers AH, Ungerleider RM, editors. Cardiopulmonary Bypass: Principles and Practice. 3rd ed. Philadelphia: LippincottWilliams & Wilkins; 2008. p. 711–35.9.Searles B, Darling E. Ultrafiltration in Cardiac Surgery. In: Mongero LB, Beck JR, editors. On Bypass: Advanced Perfusion Techniques.New Jersery: Humana Press Inc.; 2008. p. 193–210.10.McMullan DM, Elliot MJ, Cohen GA. ECMO for Infants and Children. In: Gravlee GP, Davis RF, Stammers AH, Ungerleider RM, editors.Cardiopulmonary Bypass: Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 736–56.11.Khan S, Vasavada R, Qiu F, Kunselman A, Undar A. Extracorporeal life support systems: alternative vs. conventional circuits.Perfusion. 2011;26(3):191–8.12.Ravishankar C, Gaynor JW. Circulatory Assist Devices for Infants and Children. In: Gravlee GP, Davis RF, Stammers AH, Ungerleider

RM, editors. Cardiopulmonary Bypass: Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 757–66.