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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