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Cardiopulmonary Bypass

Cardiopulmonary bypass uses a heart-lung machine to temporarily take over the function of the heart and lungs during cardiac surgery. It involves diverting blood from the veins, through an oxygenator to provide oxygen and remove carbon dioxide before returning it to the arteries. This allows the heart to be stopped, and surgery performed with a still and empty heart. Key components of the cardiopulmonary bypass system include cannulae, reservoirs, pumps, oxygenators and filters. It enables a variety of cardiac surgeries but is associated with risks of organ dysfunction.

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Parvathy R Nair
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379 views40 pages

Cardiopulmonary Bypass

Cardiopulmonary bypass uses a heart-lung machine to temporarily take over the function of the heart and lungs during cardiac surgery. It involves diverting blood from the veins, through an oxygenator to provide oxygen and remove carbon dioxide before returning it to the arteries. This allows the heart to be stopped, and surgery performed with a still and empty heart. Key components of the cardiopulmonary bypass system include cannulae, reservoirs, pumps, oxygenators and filters. It enables a variety of cardiac surgeries but is associated with risks of organ dysfunction.

Uploaded by

Parvathy R Nair
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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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

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