Cardiopulmonary Bypass

Cardiac surgery
 Coronary revascularisation (On and off pump)
 Valvular heart disease
 Surgery for heart failure
 Transplantation and assist devices
 Congenital and GUCH surgery
 Minimally invasive techniques
 Re-do surgery
 Miscellaneous (trauma, tumours, aneurysms, septal
defects, pericardiectomy, embolectomy,
dissections)
Adult Cardiac Surgery
Heart - coronary artery bypass (diagram)

                                                                                                                                                                                           
 The Heart-Lung machine
 Venous cannulae
 Venous reservoir
 Oxygenator/Heat exchanger
 Pump
 Arterial line filter
 Arterial cannula
 Cardiotomy suction
 Cardioplegia delivery system
 Venous Reservoir
 Siphons blood by gravity
 Provide storage of excess volume

 Allows escape of any air bubbles returning

with the venous blood

 Oxygenator
 Provides oxygen to the blood
 Removes carbon dioxide

 Several types

– Bubble oxygenator
– Membrane oxygenator
– Microporous hollow-fiber oxygenators
 Heat Exchanger
 Also called the heater / cooler
 Controls perfusate temperature
– Warm and cold

Q10
 Cardiopulmonary Bypass
 Heparinization
 Total bypass

 Partial bypass

 Flowrates 2-2.5 l/min. per square meter

– Flowrates depend on body size

– Flowrates depend on cannula sizes
 Hypothermia
 Shed Blood
 Is aspirated with a suctioning apparatus,
filtered and return to the oxygenator
 A cell saving device may also be utilized

during and after bypass

 Blood Pressure
 Decreases sharply with onset of bypass
(vasodilatation)
 Mean arterial pressure needs to the above

50-60 mm Hg.
 After 30 minutes perfusion pressure usually

increases (vasoconstriction)
 Oxygen and Carbon Dioxide
Tensions
 Concentrations are periodically measured in
both arterial and venous lines
 Arterial oxygen tension should be above
100 mm Hg
 Arterial carbon dioxide tensions should be
30-35 mm Hg
 A drop in venous oxygen saturation
suggests underperfusion
 Acid-Base Regulatory Strategy
 pH-stat strategy
 Aim ; constant pH,
 Total CO2 ; increased
 Intracellular state ; acidosis

 Alpha-stat strategy
• Aim; constant OH/H,
• Total CO2 ; constant ,
• Intracellular state ; neutral
 Myocardial Protection
 Cold hyperkalemic solutions
– Produces myocardial quiescence
– Decreases metabolic rate
– Provides protection for 2-3 hours
– Blood vs. crystalloid
Chemical Principles Inducing
Cardiac Arrest
 Myocardial depletion of calcium
 Myocardial depletion of sodium
 Elevation of extracellular sodium
 Elevation of extracellular magnesium
 Infusion of local anesthetic agents
 Infusion of calcium & antagonistics
Function of Cardioplegic Protection

1. Electromechanical arrest
2. Function of temperature effect
3. Function of oxygen content
4. Substrate enhancement
5. Buffering capacity
 Termination of Perfusion
 Systemic rewarming
 Flowrates are decreased

 Hemodynamic parameters

 Venous line clamping

 Pharmacologic support

 Neutralization of heparin
 Complications of Cardio-
Pulmonary Bypass

– Duration of bypass
– Age
– Cardiac function
 Organ dysfunction after bypass
 Heart: C3a and endothelin cause coronary constriction. Oedema
reduces contractility.
 Lung: Complement increases pulmonary capillary permeability.
Composition of alveolar surfactant changes. Pulmonary compliance
decrease. Pain inhibits respiration.
 CNS: Incidence of stroke 1-5%. Subtle neurological injuries up to
50% of patients.
 Kidney:Preoperative renal status and periods of low cardiac output
after CPB are the most important predictors of post-op renal function.
 GI:Liver dysfunction. Pancreatitis. GI bleeding. Mesenteric ischaemia
due to vasculitis.
 Open Heart Surgery
 Neurologic injury
 Neurologic injury is the second most common reason for
death in open heart operations
 Significant neurologic injury was observed in 2% to 5% of
patients, whereas mild cognitive dysfunction was seen in
70% of patients in the early stage
 Extracorporeal circulation does not cause changes in brain
blood circulation, but hemodilution and decrease in oncotic
pressure lead to edema in the brain and in other organs
 Cerebral ischemia due to microemboli or macroemboli,
systemic inflammatory response, and cerebral
hypoperfusion during cardiopulmonary bypass (CPB)
causes impairment in the blood brain barrier.
Optimal Neurologic Protection
 Variables
 Perfusion pressure
 Flow rate
 Duration of cooling
 Duration of circulatory arrest
 Hematocrit
 Ultrafiltration
 Blood gas strategy
 Presence of collateral flow
 Impact of age
 Postpump Syndrome on Lung

 Characteristics
 Increased alveolo-arterial gradient
(A-aDO2) and intrapulmonary shunt
 Decreased pulmonary compliance

 Increased pulmonary vascular resistance

 Increased pulmonary vascular perrmeability

 IABP Background
 Preload
 Afterload

 Coronary flow

 Myocardial oxygen consumption in the

heart is determined by:
– Pulse rate
– Transmural wall stress
– Intrinsic contractile properties
Myocardial Oxygen Consumption
 Has a linear relationship to:
– Systolic wall stress
– Intraventricular pressure
– Afterload
– End diastolic volume
– Wall thickness
 IABP in Myocardial Infarction
and Cardiogenic Shock
 Improves diastolic flow velocities after
angioplasty
 Allows for additional intervention to be

done more safely

 IABP During or After Cardiac
Surgery
 Patients who have sustained ventricular
damage preoperatively and experience
harmful additional ischemia during surgery
 Some patients begin with relatively normal

cardiac function an experienced severe, but

reversible, myocardial stunning during the
operation
 Other Indications for IABP
 Prophylactic use prior to cardiac surgery in
patients with:
– Left main disease
– Unstable angina
– Poor left ventricular function
– Severe aortic stenosis
Contraindications to IABP
 Severe aortic insufficiency
 Aortic aneurysm

 Severe ilio-femoral vessel disease

 Insertion Techniques
 Percutaneous
– sheath less
 Surgical insertion

Positioning
The end of the balloon should be just distal to the takeoff of
the left subclavian artery
Position should be confirmed by fluoroscopy or chest x-ray
 Timing of Counterpulsation
•Electrocardiographic
•Arterial pressure tracing
 Complications
 Limb ischemia
– Thrombosis
– Emboli
 Bleeding and insertion site
– Groin hematomas
 Aortic perforation and/or dissection
 Renal failure and bowel ischemia
 Neurologic complications including paraplegia
 Heparin induced thrombocytopenia
 Infection