Air Transmission Comparison of the Affinity Fusion Oxygenator with an Integrated Arterial Filter to the Affinity NT Oxygenator with a Separate Arterial Filter.

Arterial filters used in the extracorporeal circuit (ECC) have been shown to minimize cerebral injury by capturing particulate matter and microbubbles. We clinically use the Affinity NT oxygenator with an Affinity arterial filter attached ("Affinity system"). The new Affinity Fusion oxygenator ("Fusion") incorporates integrated arterial filtering. Our aim was to determine if the Fusion oxygenator was as safe as the Affinity system in terms of relative microbubble transmission of introduced air. A recirculating in vitro circuit primed with blood was used to compare the Fusion with the Affinity system. Microbubbles were detected using a GAMPT BC100 Doppler in the oxygenator-arterial filter outflow line. Measurements were taken 1 minute before and 3 minutes after bolusing 30 mL air proximal to the venous reservoir while altering pump flow rates (3 L/min; 5 L/min). Both the Fusion and Affinity system transmitted microbubbles during air injection. Microbubble volume transmitted at 5 L/min pump flow was significantly greater than at 3 L/min in both systems. The Fusion tended to transmit fewer bubbles, less bubble volume, and smaller sized bubbles than the Affinity system. Under the parameters of this in vitro study, the Affinity Fusion oxygenator with an integrated arterial filter is as safe as the Affinity NT oxygenator with a separate arterial filter in terms of microbubble transmission. However, more research is needed to confirm this study's findings and generalizability to the clinical environment. As both oxygenator-arterial filter systems transmitted microbubbles during air introduction, it is important to develop strategies to minimize microbubble entry into the ECC.

Microbubble transmission during cardiotomy infusion of a hardshell venous reservoir with integrated cardiotomy versus a softshell venous reservoir with separated cardiotomy: an in vitro comparison.

An important mechanism for postoperative cognitive impairment after cardiac surgery using cardiopulmonary bypass (CPB) is microemboli. One component of the CPB circuit-the cardiotomy-is a major source of gaseous microemboli because it aspirates significant volumes of air with blood from the operative field and intracardiac chambers. Cardiotomies are either integrated within an open hardshell venous reservoir (IC-HSVR) or are a separate canister attached to a softshell collapsible venous reservoir bag (SC-SSVR). The purpose of this study was to compare the Medtronic IC-HSVR (Affinity NT CVR) with Medtronic's SC-SSVR (CB 1351, CBMVR 1600) in terms of relative microbubble transmission during cardiotomy infusion. A recirculating in vitro circuit primed with blood was used to compare the two cardiotomy-reservoir systems with the venous reservoir in the SC-SSVR further assessed in a fully closed or partially open state (SC-SSVR-closed; SC-SSVR-open). Microbubbles were detected using a GAMPT BC100 Doppler system in the outflow line of the venous reservoir. Measurements were taken before (baseline) and after aerated prime was pumped into the cardiotomy while altering pump flow rates (3 L/min; 5 L/min) and reservoir prime volumes (400 mL; 900 mL). Infusing cardiotomy blood into the venous reservoir was associated with an increase in microbubbles and bubble volume transmitted by both cardiotomy-reservoir systems with the magnitude rising with reduced prime volumes. The effect was markedly greater with the IC-HSVR. The IC-HSVR also transmitted larger bubbles, particularly with reduced prime volumes. There was no significant difference in microbubble transmission seen between the SC-SSVR-closed and SC-SSVR-open. The SC-SSVR transmits fewer microbubbles than the IC-HSVR during cardiotomy infusion and should be considered as the preferential system. Because both cardiotomy-reservoir systems transmitted microbubbles during cardiotomy infusion, particularly at the lower venous reservoir volume, it is important to use strategies to minimize cardiotomy microbubble infusion.

Microbubble generation and transmission of medtronic's affinity hardshell venous reservoir and collapsible venous reservoir bag: an in-vitro comparison.

Microemboli are implicated in neurological injury; therefore, the extracorporeal circuit (ECC) should not generate microbubbles or transmit introduced air. The venous reservoir is the first component in the ECC designed to remove introduced air. The purpose of this study was to investigate the relative safety of two kinds of adult venous reservoirs--the closed soft-shell venous reservoir (SSVR [Medtronic CBMVR 1600]) and the open hard-shell venous reservoir (HSVR [Affinity NT CVR])--in terms of microbubble generation and introduced air transmission. A recirculating in-vitro circuit was used to compare the two reservoirs with the SSVR further assessed in a fully closed or partially open state. Microbubbles were counted using a Hatteland CMD-10 Doppler in the outflow of the reservoirs before (microbubble generation) and after infusing 20 mL/min of air into the venous line (microbubble transmission) while altering pump flow rates (3 L/min; 5 L/min) and reservoir prime (200 mL; 700 mL). Negligible bubble generation was noted in the SSVRs at both flow rates and either reservoir volume. However, microbubble generation was significant in the HSVR at the higher flow rate of 5 L/min and lower reservoir volume of 200 mL. When infusing air, a flow of 3 L/min was associated with insignificant to small increases in microbubble transmission for all reservoirs. Conversely, infusing air while flowing at 5 L/min was associated with significantly more microbubble transmission for all reservoirs at both low and high reservoir volumes.The SSVR is as safe as the HSVR in microbubble handling as the generation and transmission of microbubbles by the SSVR is not more than the HSVR over a range of prime volumes and flow rates. As both reservoirs transmitted microbubbles at higher pump flow rates regardless of reservoir volumes, it is important to eliminate venous air entrainment during cardiopulmonary bypass.

Blood management issues: getting clots together when you want them.

Coagulation is a complex process that allows whole blood to form clots at tissue and vessel sites where damage has occurred. Activation of the hemostasis system causes platelets and fibrin-containing clot to stop the bleeding. Perfusionists must find ways to preserve the coagulation system if we are to avoid bleeding in the cardiopulmonary bypass patient. It is still unclear what techniques are best to continue maintaining hemostasis and avoiding transfusion in patients requiring cardiopulmonary bypass (CPB). There are numerous factors that come into play with the use of CPB including deactivating the coagulation system with anticoagulants, hemodilution of the circulating blood volume, inflammatory response, and a possible pro-coagulant response from protamine with heparin reversal once the surgical procedure has been completed and CPB terminated. All these factors make achieving hemostasis post CPB extremely difficult. This review attempts to assess what is currently being discussed in the literature, which may improve hemostasis with cardiopulmonary bypass. There is still no one technique that will improve hemostasis post CPB. Perhaps the answer may lie in a combination of reported techniques that may in some way lead to the preserving of coagulation factors during CPB.

Anaortic techniques reduce neurological morbidity after off-pump coronary artery bypass surgery.

BACKGROUND: Stroke remains one of the most devastating complications of cardiac surgery. Advocates of off-pump coronary revascularisation (OPCAB) maintain that post-operative neurologic morbidity is reduced by avoiding aortic cannulation and cross-clamping, and by eliminating the systemic effects of cardiopulmonary bypass. We sought to determine whether completing off-pump coronary surgery without any aortic manipulation ("anaortic" technique) afforded any additional neurological protection, as compared to off-pump grafting in which the aorta was utilised for graft inflow. METHODS: A comprehensive review of prospectively collected data was undertaken of all patients undergoing OPCAB in our institution between January 2002 and December 2006. Cases requiring intra-operative conversion to cardiopulmonary bypass were excluded from further analysis. Patients having OPCAB surgery with aortic manipulation were compared to those having OPCAB surgery without aortic manipulation. Multiple logistic regression was used to identify possible predictors of post-operative neurologic morbidity, with particular focus on the role of aortic manipulation. RESULTS: During the period of review, 1758 patients underwent OPCAB, of which 1201 (68.3%) were completed without aortic manipulation, constituting the "anaortic" cohort. This group was compared with the remaining 557 patients, which included fashioning at least one aorto-conduit anastomosis, utilising either a side-biting aortic clamp or a no-clamp proximal anastomotic device. The two groups of patients were well-matched with respect to risk factors for adverse neurologic outcomes. Nine patients sustained focal neurological deficits (transient or permanent) in the peri-operative period, constituting a stroke rate of 0.51% for the entire series. The incidence of peri-operative neurological deficit in the anaortic group was 0.25% compared with 1.1% in the aortic manipulation group (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.06-0.92, p=0.037). Advanced age was also associated with peri-operative neurological injury (OR 1.1, 95% CI 1.01-1.20, p=0.017). CONCLUSIONS: Off-pump coronary artery surgery is associated with a low incidence of peri-operative stroke. Completing the surgical procedure without manipulating the ascending aorta in any way ("anaortic" technique) offers additional neurological protection and should be the goal in all suitable off-pump coronary cases.

Transfusion and bleeding in coronary artery bypass grafting: an on-pump versus off-pump comparison.

Blood transfusion rates in coronary artery bypass grafting (CABG) surgery using cardiopulmonary bypass (CPB) are typically higher compared with off-pump CABG (OPCAB). However, few studies have specifically examined intraoperative hemodilution as a contributing factor. The aim of this retrospective review was to compare the effect of using CPB or OPCAB on red blood cell (RBC) transfusion and postoperative bleeding. The lowest intraoperative hematocrit (Hct) was used as marker of intraoperative hemodilution. We reviewed the perioperative data of all isolated CABG patients at a metropolitan hospital from January 2003 to June 2005. Stepwise regression analyses were performed to determine whether CPB was an independent predictor of RBC transfusion, reoperation for bleeding, or postoperative chest drainage. Of a total of 1043 patients, there were 433 CPB and 610 off-pump cases. CPB use was not significantly related to increased RBC transfusions (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.63-1.52; p = .921) and was associated with a lower incidence of reoperations for bleeding (OR, 0.4; 95% CI, 0.2-0.8; p = .009). There was less chest drainage over the first 12 hours in patients undergoing CPB (p < .0001); however, total postoperative chest drainage was not significantly related to operative procedure (p = .122). The lowest documented intraoperative Hct was a significant factor in RBC transfusions (OR, 0.89; p < .0001), an increased reoperation rate for bleeding (OR, 0.9; p = .001) and more postoperative chest drainage (log10-transformed: at 12 hours, b = -0.009, p < .0001; total, b = -0.006, p < .0001). CPB is not an independent risk factor in the incidence of RBC transfusions and is not associated with increased postoperative bleeding for isolated CABG. However, intraoperative hemodilution is an independent risk factor, with a lower intraoperative Hct associated with more RBC transfusions, increased reoperations for bleeding, and increased postoperative chest drainage. Addressing intraoperative hemodilution is important in minimizing CPB-associated morbidities.

In vitro validation of the Affinity NT oxygenator arterial outlet temperatures.

During cardiopulmonary bypass, the rates of cooling and rewarming and the maximum temperatures attained are implicated in patient morbidity. Thus, accurate oxygenator arterial outlet temperature measurements are needed. The purpose of this study was to determine the accuracy of the arterial outlet temperature probe on the "Affinity NT" membrane oxygenator in measuring perfusate temperatures. An in vitro circuit was used. Crystalloid solution was recirculated through an Affinity NT membrane oxygenator and, to simulate the patient, a second oxygenator. Water was recirculated through the heat exchanger of the second oxygenator via a reservoir. A myocardial temperature probe was inserted in-line 4 cm distal to the Affinity NT oxygenator arterial outlet temperature probe and was considered to measure the actual temperature of the perfusate. Temperatures were simultaneously recorded from the in-line probe, arterial outlet probe, and reservoir every second. Twenty-seven trials were run using random combinations of three Affinity NT oxygenators and three in-line probes. Each trial entailed cooling an initially normothermic reservoir to 28 degrees C and then rewarming it to normothermia again. The arterial outlet temperature probe on the Affinity NT membrane oxygenator underestimated the perfusate temperatures during early rewarming (bias of 0.72 degrees C; precision of +/-1.15 degrees C) and late rewarming (bias of 0.52 degrees C; precision of +/-0.97 degrees C). An overestimation of the perfusate temperatures occurred during early cooling (bias of -0.57 degrees C; precision of +/-1.37 degrees C). Only during the late cooling phase was the arterial outlet temperature probe accurate (bias of -0.02 degrees C; precision of +/-0.3 degrees C). The perfusionist should be aware of the temperature probe monitoring characteristics of the oxygenator to safely perfuse the patient.

Membrane oxygenator exhaust capnography for continuously estimating arterial carbon dioxide tension during cardiopulmonary bypass.

Typically, the standard practice for measuring the arterial blood carbon dioxide tension (PaCO2) during cardiopulmonary bypass (CPB) is to take intermittent blood samples for analysis by a bench blood gas analyzer. Continuous inline blood gas monitors are available but are expensive. A potential solution is the capnograph, which was evaluated by determining how accurately the carbon dioxide tension in the oxygenator exhaust gases (PECO2) predicts PaCO2. A standard capnograph monitoring line was attached to the exhaust port of the membrane oxygenator. During CPB, the capnograph reading and arterial blood temperature were recorded at the same time as routine arterial blood gases were taken. One hundred fifty-seven blood samples were collected from 78 patients. A good correlation was found between the PECO2 and the temperature corrected PaCO2 (r2 = 0.833, P < .001). There was also a reasonable degree of agreement between the PECO2 and the temperature corrected PaCO2 during all phases of CPB: accuracy (bias or mean difference between PaCO2 and PECO2) of -1.2 mmHg; precision (95% limits of agreement) of +/- 4.7 mmHg. These results suggest that oxygenator exhaust capnography may be a simple and inexpensive adjunct to the bench blood gas analyzer in continuously estimating PaCO2 of a clinically useful degree of accuracy during CPB.

Coronary artery bypass grafting: an off-pump versus on-pump review.

There has been a proliferation in the number of coronary artery bypass grafts (CABG) being performed without the use of cardiopulmonary bypass (CPB). However, the benefits of off-pump coronary artery grafting (OPCAB) are still being determined. The aim of this retrospective review was to compare the perioperative outcomes of CPB patients with OPCAB patients and to identify the patients most likely to benefit from the off-pump procedure. We reviewed the perioperative data of all isolated CABG patients at two metropolitan hospitals for the period of August 2000 to September 2001. The two groups (OPCAB vs. CPB) were further divided into subgroups identifying patients by their predicted mortality (higher-risk and lower-risk) and the number of distal graft anastomoses received (1, 2, 3, 4, or 5). A p value less than .05 was considered significant. Out of the total of 882 patients, 46.2% were OPCAB cases. Both CPB and OPCAB groups were similar in terms of demographics and predicted risk of mortality. Intraoperatively, OPCAB patients had fewer distal graft anastomoses (2.4 +/- 1.0 vs. 3.2 +/- 1.0, p < .001). Postoperatively, patients in the OPCAB group had less chest drainage (889 +/- 588 vs. 989 +/- 662 mls, p < .001), sustained fewer strokes (0.2 vs. 1.9%, p < .05), were transfused less (15.4 vs. 32.5%, p < .001) and were discharged earlier (7.3 +/- 5.6 vs. 8.5 +/- 9.1 days, p < .05). For higher-risk patients, OPCAB was associated with fewer reoperations for bleeding (1.3 vs. 6.4%, p < .05), a lower stroke rate (0 vs. 3.2%, p < .05), and a trend toward lower mortality (7.1 vs. 15.1%, p = .08). However, lower-risk OPCAB patients' stroke incidences (0.5% OPCAB group vs. 1.4% CPB group), and mortality rates (0.5 vs. 0.5%) were similar. Comparisons by number of grafts performed revealed that only the single-grafted OPCAB patients had statistically fewer postoperative complications, reduced chest drainage, and a shorter intensive care stay. Differences between either operation groups in transfusion rates were only statistically significant for the one to three grafted patients, while postoperative stays were similar for patients having four grafts. These results suggest that OPCAB is associated with a reduction in mortality and morbidity, particularly within the higher-risk patients. However, the benefits of OPCAB diminished with an increasing number of distal anastomoses performed.