The Safe Addition of Nitric Oxide into the Sweep Gas of the Extracorporeal Circuit during Cardiopulmonary Bypass and Extracorporeal Life Support.

Low cardiac output syndrome and the systemic inflammatory response are consequences of the cardiac surgical perioperative course. The mechanisms responsible are multifactorial, but recent studies have shown that nitric oxide (NO) may be a key component in mitigating some of these processes. Following on from literature reports detailing the use of inhaled NO added to the gas phase of the extracorporeal circuit, we set about developing a technique to perform this addition safely and efficiently. In the setting of cardiopulmonary bypass, the technique was validated in a randomized prospective trial looking at 198 children. The benefits observed in this trial then stimulated the incorporation of NO into all extracorporeal life support (ECLS) circuits. This required additional hardware modifications all of which were able to be performed safely. Initial results from the first series of ECLS patients using NO also appear promising.

Vascular access for pediatric coronary angiography on extracorporeal membrane oxygenation.

Vascular access for catheterization of a pediatric patient on extracorporeal membrane oxygenation (ECMO) was facilitated by adding an accessory limb to the ECMO circuit. This limb was terminated with a hemostatic valve allowing insertion of a catheter. Changes in support parameters compensated for the change in the effective diameter of the ECMO cannula on insertion of the catheter. This method can overcome difficulties in obtaining vascular access for patients on ECMO.

Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience.

BACKGROUND: Studies on long-term outcomes of the arterial switch operation (ASO) for transposition of the great arteries (TGA) are uncommon. Thus, we sought to determine the long-term outcomes for patients after ASO performed at a single institution over a 25-year period. METHODS: From 1983 to 2009, 618 patients underwent the ASO for TGA and were reviewed retrospectively. RESULTS: Overall early mortality was 2.8%. Risk factors for early death on multivariate analysis were resection of left ventricular outflow tract obstruction at time of ASO (p = 0.001), weight less than 2.5 kg at time of ASO (p < 0.001), associated aortic arch obstruction (p = 0.043), and the need for postoperative extracorporeal membrane oxygenation (p < 0.001). Mean follow-up time was 10.6 years (range 2 months to 26.1 years). Late mortality was 0.9%. Reintervention was significantly higher (p < 0.001) in patients with ventricular septal defect or arch obstruction versus those without them (25.2% and 23.4% vs 5.9% at 15- year follow-up). Risk factors for late reintervention were left ventricular outflow tract obstruction at time of ASO (p < 0.001) and a greater circulatory arrest time (p < 0.001). Freedom from at least moderate neoaortic valve regurgitation for the entire cohort was 98.7% (95% confidence interval 96.8 to 99.5%) at 20 years. Mild neoaortic regurgitation was seen in 25.6% of patients at mean follow-up. All patients were free of arrhythmia and heart failure symptoms at last follow-up. CONCLUSIONS: The ASO can be performed with good long-term results. Patients with associated ventricular septal defect and aortic arch obstruction warrant close follow-up.

Integrated Oxygenator FX05.

In recent years, there has been a trend to incorporate arterial filters into cardiopulmonary bypass (CPB) oxygenators. The FX oxygenators are the first examples of integrating a filter around the fibers of the oxygenator. To assess the efficacy of the FX05 oxygenator, in comparison with our existing CPB setup (RX05 oxygenator + arterial filter), we randomly assigned 40 patients undergoing CPB, with calculated flows <1.5 L/min, to FX05 or RX05 + arterial filter (19 FX and 21 RX). Embolic load was assessed using the emboli detection and classification quantifier, with sensors placed prefilter and postfilter/oxygenator at identical distances for both devices. A total of 6,270 FX readings and 6,183 RX readings were obtained. Because of the extremely skewed nature of the data, the prefilter embolic volumes were divided into deciles, and each decile was analyzed separately. Our results show that the devices perform similarly; both filter out a high percentage of the prefilter embolic load. Our data support that in the clinical setting, the FX05 is as effective at removing emboli as the RX05 with an arterial filter (CXAF02) which, in conjunction with the prime volume reduction and circuit simplification, has warranted our conversion to the FX series of oxygenators.

Rationale and use of perfusion variables in the 2010 update of the society of thoracic surgeons congenital heart surgery database.

Patients undergoing congenital heart surgery are at risk of morbidity and mortality. The reasons underlying this risk are complex. To identify opportunities to reduce adverse sequelae, the cardiovascular perfusion community was invited to amend existing perfusion-related fields as well as add new ones to the current version of the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). The International Consortium for Evidence-Based Perfusion (ICEBP) was invited by the STS-CHSD Task Force to identify and resolve ambiguities related to definitions among the 3 current perfusion-related fields as well as to propose new variables (and definitions) for inclusion in the 2010 update of the STS-CHSD. The ICEBP used teleconferences, wiki-based communication software, and e-mail to discuss current definitions and create new fields with definitions. The ICEBP created modified definitions to existing fields related to cardiovascular perfusion and also developed and defined new fields that focus on (1) techniques of circulatory arrest and cerebral perfusion, (2) strategies of myocardial protection, and (3) techniques to minimize hemodilution and allogeneic blood transfusions. Three fields in the STS-CHSD related to perfusion were redefined, and 23 new variables and definitions were selected for inclusion. Identifying and defining fields specific to the practice of perfusion are requisite for assessing and subsequently improving the care provided to patients undergoing congenital heart surgery. The article describes the methods and justification for adjudicating extant and new perfusion-related fields added to the 2010 update of the STS-CHSD.

Complications relating to perfusion and extracorporeal circulation associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease.

The International Consortium for Evidence-Based Perfusion (www.bestpracticeperfusion.org) is a collaborative partnership of societies of perfusionists, professional medical societies, and interested clinicians, whose aim is to promote the continuous improvement of the delivery of care and outcomes for patients undergoing extracorporeal circulation. Despite the many advances made throughout the history of cardiopulmonary bypass, significant variation in practice and potential for complication remains. To help address this issue, the International Consortium for Evidence-Based Perfusion has joined the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease to develop a list of complications in congenital cardiac surgery related to extracorporeal circulation conducted via cardiopulmonary bypass, extracorporeal membrane oxygenation, or mechanical circulatory support devices, which include ventricular assist devices and intra-aortic balloon pumps. Understanding and defining the complications that may occur related to extracorporeal circulation in congenital patients is requisite for assessing and subsequently improving the care provided to the patients we serve. The aim of this manuscript is to identify and define the myriad of complications directly related to the extracorporeal circulation of congenital patients.

The use of extracorporeal life support in the treatment of influenza-associated myositis/rhabdomyolysis.

A 13-year-old girl presented to the emergency department with fatigue, headaches and muscle stiffness after returning from a family camping trip. Within 24 h, she was transferred to ICU with general oedema and low saturations, where she had a cardio-respiratory arrest and was placed on veno-arterial extracorporeal membrane oxygenation (ECMO). The patient was successfully supported with ECMO for profound myocardial dysfunction and haemofiltration for rhabdomyolysis and acute renal failure. Patients who present with profound myocardial dysfunction and myoglobinuria as a consequence of viral infection can be successfully supported with ECMO.

New technology increases perioperative haemoglobin levels for paediatric cardiopulmonary bypass: what is the benefit?

Increasing perioperative haemoglobin level by reducing priming volume and maintaining a safe cardiopulmonary bypass (CPB) system is the aim of every perfusionist. In this study, we have compared the two membrane oxygenators and pump systems used for paediatric bypass at the Royal Children's Hospital on a regular basis since 1988. We looked at all patients who had the Cobe VPCML (Cobe Laboratories, Denver, CO, USA) and Terumo RX-05 (Terumo Corporation, Tokyo, Japan) oxygenators used for flows from 800 mL/min up to the maximum rated flow for the respective oxygenator from January 2002 until March 2004. The VPCML refers to using only the 0.4-m2 section of the oxygenator. The pump systems used were the Stöckert CAPS (Stöckert Instrumente GmbH, Munich, Germany) and Jostra HL 30 (Jostra AB, Lund, Sweden). Changing from the VPCML to the RX-05 resulted in a 37% reduction in priming volume. The introduction of the Jostra HL 30 with a custom-designed mast system reduced the priming volume by another 15%. This change in priming volume allowed a significant increase, from 6 to 34%, in the percentage of patients who received bloodless primes, and for those patients who received blood primes, an increase in haemoglobin (Hb) on bypass from 8.2 to 9.6 g/dL, on average.