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Minimal invasive Extra-Corporeal Circulation (MiECC): A revolutionary

evolution in perfusion

Article  in  Interactive Cardiovascular and Thoracic Surgery · October 2014

DOI: 10.1093/icvts/ivu304

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Interactive CardioVascular and Thoracic Surgery 19 (2014) 541–542
doi:10.1093/icvts/ivu304
Minimal invasive Extra-Corporeal Circulation (MiECC):
a revolutionary evolution in perfusion†
Kyriakos Anastasiadisa, Adrian Bauerb, Polychronis Antonitsisa, Erich Gygaxc,
Jan Schaarschmidtb,* and Thierry Carrelc
a
Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
b
Department of Cardiovascular Perfusion, MediClin Heart Centre Coswig, Coswig, Germany
c
Department of Cardiovascular Surgery, University Hospital, Bern, Switzerland
* Corresponding author. MediClin Heart Centre Coswig, Department of Cardiovascular Perfusion, 06869 Coswig, Germany. Tel: +49-34903-49351;
fax: +49-34903-49359; e-mail: jan.schaarschmidt@mediclin.de ( J. Schaarschmidt).
Since the beginning of extracorporeal circulation (ECC) in
cardiac surgery, a multitude of changes and improvements were
aimed to reduce the adverse systemic effects caused by the arti-
ficial surfaces of the perfusion circuit. The clinical picture is
similar to a systemic inflammatory response syndrome [1]. The
magnitude of the inflammatory response adversely influences
clinical outcomes [2]. Hence, the overall morbidity associated
with cardiac surgery is substantial [3]. The off-pump coronary
artery bypass (OPCAB) technique was introduced as a strategy to
decrease the side effects of cardiopulmonary bypass (CPB). But
the real advantages of OPCAB have been questioned in recent
years [4].
In the early 2000s, a simplified perfusion system comprising all
technological advancements was designed [5]. The modifications
of the new system were much more revolutionary than the indi-
vidual improvements to the existing conventional CPB circuits.
The idea was to create a system including all established benefits
in one CPB set-up. The Minimal Extra-Corporeal Circulation
(MiECC) technology was born.
Since then, MiECC systems have been developed to increase
the technical ease of on-pump surgery while tempering its disad-
vantages. For many years, cardiac surgeons, anaesthesiologists
and perfusionists considered MiECC systems as a miniaturization
or simplification of traditional CPB only. MiECC significantly atte-
nuated morbidity attributed to conventional ECC, as for beating-
heart procedures, while permitting optimal technical surgical con-
ditions [6]. ‘The authors believe that MiECC technology represents
more than a miniaturization process: it is a major step forward and
a totally new philosophy to be integrated in contemporary cardiac
surgery’. The idea of MiECC systems has initiated new efforts
to improve the biocompatibility of CPB systems and minimize
their side effects, offering finally better postoperative end-organ
function. Characteristics of MiECC include the following: (1) a
blood pump with optimal biocompatibility, low thrombogenicity,
minimal haemolysis and activation of leucocytes as well as proin-
flammtory mediators; (2) a minimal tubing length to reduce the
†
Feedback from the 1st International Symposium on Minimal invasive
Extracorporeal Circulation Technologies, Thessaloniki, Greece, 13–14 June
2014.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
EDITORIAL – ADULT CARDIAC
EDITORIAL
priming volume required and thus minimize haemodilution, de-
creasing the need for foreign blood transfusions; (3) coated
surfaces to reduce protein adsorption and platelet activation; (4)
separation of shed blood and exclusion of activated blood com-
ponents via cell salvage; (5) closed system to avoid blood–air
contact; (6) temperature management depending on the need
and magnitude of surgery should be possible; (7) use of modern
concepts of myocardial protection, like blood cardioplegia, must
be easy to integrate; (8) safe de-airing must be possible following
open heart procedures; (9) finally, it should help modern concepts
of fast-track anaesthesia [7, 8]. These characteristics will help to
make MiECC an element of a minimal invasive procedure rather
than simply a miniaturized CPB system.
Numerous randomized clinical studies have proved that MiECC
exerts significant beneficial effects on postoperative morbidity, by
reducing haemodilution, mediastinal bleeding, need for blood
transfusion and inflammatory response. Clinical benefits are:
improved end-organ (myocardial, renal and cerebral) protection
and reduction of the length of intensive care unit stay [5–8].
Moreover, it is associated with a significant survival benefit in cor-
onary procedures compared with conventional ECC as shown in a
recent meta-analysis. This analysis reported randomized trials in-
cluding 24 studies with a total of 2770 patients [9] and provided a
Scientific Class I, Level of evidence A for implementation of
MiECC, at least for coronary revascularization.
Despite these clear clinical advantages, penetration of the
MiECC technology into clinical practice remains significantly
low. Thus, the authors took the initiative to organize the ‘1st
International Symposium on Minimal invasive Extracorporeal
Circulation Technologies (1st MiECT)’ in Thessaloniki, Greece
during June 13–14 to create a dedicated international forum to
stimulate the exchange of ideas in clinical application and re-
search in the field of Minimal invasive Extracorporeal Circulation
Technology without geographical bias (www.miect.org).
More than 400 participants from all continents registered.
Beside scientific sessions, wet-labs with two simulators for
‘hands-on training’ allowed participants to practice on all com-
mercially available MiECC systems. Twenty abstracts were selected
for publication and are part of this Interactive Cardiovascular and
Thoracic Surgery issue. During the congress, the ‘Minimal invasive
 542 K. Anastasiadis et al. / Interactive CardioVascular and Thoracic Surgery
Extracorporeal Circulation Technologies international Society
(MiECTiS)’ was founded. This is an initial step to bring together
cardiothoracic surgeons, anaesthesiologists, perfusionists, basic
researchers and industry to promote application of MiECC world-
wide. A consensus paper will be prepared later this year with the
corporate effort of the Steering Committee, Founding Members
and experts on the MiECC.
Discussions showed that refinements in perfusion technol-
ogy have contributed to answering open questions regarding
MiECC safety. Introduction of modular systems finds many
advocates within the cardiac surgical and perfusion commu-
nity. The term ‘modular’ refers to the possibility of integrating
different components, such as, for example an additionally
mounted, clamped-off venous reservoir, which allows the per-
fusionist to run the system as an open circuit, if required. This
strategy offers an additional ‘safety net’ in case of an unexpect-
ed intraoperative event.
We conclude that a wider application of an integrated minimal
invasive strategy regarding CPB, called ‘MiECC strategy’, is a fun-
damental step towards improved patient perfusion during surgi-
cal cardiac procedures. There is an immense need for large
multicentre prospective randomized studies to confirm potential
clinical benefits resulting from MiECC in different surgical proce-
dures. We strongly believe that MiECC could finally replace con-
ventional CPB.
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