Cardiopulmonary

bypass

Cardiopulmonary bypass (CPB) is a

technique in which a machine temporarily
takes over the function of the heart and
lungs during surgery, maintaining the
circulation of blood and the oxygen
content of the patient's body. The CPB
pump itself is often referred to as a heart–
lung machine or "the pump".
Cardiopulmonary bypass pumps are
operated by perfusionists. CPB is a form
of extracorporeal circulation.
Extracorporeal membrane oxygenation is
generally used for longer-term treatment.
 Cardiopulmonary bypass

A heart–lung machine (upper right) in a coronary

artery bypass surgery.

ICD-9-CM 39.61

MeSH D002318

OPS-301 code 14

Other codes 22570829

[edit on Wikidata]

Uses
Illustration of one typical way that a heart-lung
machine may be connected to the veins and arteries
near the heart. The three implements on the left
represent (from top to bottom) the pump, the
oxygenator, and the reservoir.

Cardiopulmonary bypass is commonly

used in coronary bypass heart surgery
because of the difficulty of operating on
the beating heart. Operations requiring the
opening of the chambers of the heart
requires the use of CPB to avoid engulfing
air systemically and to provide a bloodless
field to increase visibility for the surgeon.
The machine pumps the blood, and, using
an oxygenator, allows red blood cells to
pick up oxygen, as well as allowing carbon
dioxide levels to decrease. This mimics
the function of the heart and the lungs,
respectively.

CPB can be used for the induction of total

body hypothermia, a state in which the
body can be maintained for up to 45
minutes without perfusion (blood flow). If
blood flow is stopped at normal body
temperature, permanent brain damage
normally occurs in three to four minutes –
death may follow shortly afterward.
Similarly, CPB can be used to rewarm
individuals suffering from hypothermia.[1]
This rewarming method of using CPB is
successful if the core temperature of the
patient is above 16 °C. [2]

Extracorporeal membrane oxygenation

(ECMO) is a simplified version of the heart
lung machine that includes a centrifugal
pump and an oxygenator to temporarily
take over the function of heart and/or the
lungs. ECMO is useful in post cardiac
surgery patients with cardiac or pulmonary
dysfunction, in patients with acute
pulmonary failure, massive pulmonary
embolisms, lung trauma from infections,
and a range of other problems that impair
cardiac or pulmonary function. ECMO
gives the heart and/or lungs time to repair
or recover but it's only a temporary
solution. Patients with terminal conditions,
cancer, severe nervous system damage,
uncontrolled sepsis and other conditions
may not be candidates for ECMO.[3]

CPB mechanically circulates and

oxygenates blood for the body while
bypassing the heart and lungs. It uses a
heart–lung machine to maintain perfusion
to other body organs and tissues while the
surgeon works in a bloodless surgical
field. The surgeon places a cannula in the
right atrium, vena cava, or femoral vein to
withdraw blood from the body. The
cannula is connected to tubing filled with
isotonic crystalloid solution. Venous blood
which is removed from the body by the
cannula is filtered, cooled or warmed,
oxygenated, and then returned to the body.
The cannula used to return oxygenated
blood is usually inserted in the ascending
aorta, but it may be inserted in the femoral
artery. The patient is administered heparin
to prevent clotting, and protamine sulfate
is given after to reverse effects of heparin.
During the procedure, hypothermia may be
maintained; body temperature is usually
kept at 28 °C to 32 °C (82.4–89.6 °F). The
blood is cooled during CPB and returned
to the body. The cooled blood slows the
body's basal metabolic rate, decreasing its
demand for oxygen. Cooled blood usually
has a higher viscosity, but the crystalloid
solution used to prime the bypass tubing
dilutes the blood.

Surgical procedures in which

cardiopulmonary bypass is
used

Coronary artery bypass surgery

Cardiac valve repair and/or replacement
(aortic valve, mitral valve, tricuspid valve,
pulmonic valve)
Repair of large septal defects (atrial
septal defect, ventricular septal defect,
atrioventricular septal defect)
Repair and/or palliation of congenital
heart defects (Tetralogy of Fallot,
transposition of the great vessels)
Transplantation (heart transplantation,
lung transplantation, heart–lung
transplantation, liver transplantation)
Repair of some large aneurysms (aortic
aneurysms, cerebral aneurysms)
Pulmonary thromboendarterectomy
Pulmonary thrombectomy
 Isolated Limb perfusion[4]

History

A heart lung machine used in London's Middlesex

Hospital in 1958. Science Museum, London (2008)

An Austrian-German physiologist
Maximilian von Frey constructed an early
prototype of a heart-lung machine in 1885
at Carl Ludwig’s Physiological Institute of
the University of Leipzig.[5] However, such
machines were not feasible before the
discovery of heparin in 1916 which
prevents blood coagulation. A Soviet
scientist Sergei Brukhonenko developed a
heart-lung machine for total body
perfusion in 1926 which was used in
experiments with canines. Dr. Clarence
Dennis led the team that conducted the
first known operation involving open
cardiotomy with temporary mechanical
takeover of both heart and lung functions
on April 5, 1951 at the University of
Minnesota Hospital. The patient did not
survive due to an unexpected complex
congenital heart defect. This followed four
years of laboratory experimentation with
dogs with a unit called the Iron Heart. A
team of scientists at Birmingham
University (including Eric Charles, a
chemical engineer) were among the
pioneers of this technology.[6][7] Another
member of the team was Dr. Russell M.
Nelson , current president of The Church
of Jesus Christ of Latter-day Saints, who
performed the first open heart surgery in
Utah.[8]
Brukhonenko's Autojektor

The first successful mechanical support of

left ventricular function was performed in
July 3, 1952 by Forest Dewey Dodrill using
a machine, the Dodrill-GMR co-developed
with General Motors. The machine was
later used to support right ventricular
function.[9]

The first successful open heart procedure

on a human utilizing the heart lung
machine was performed by John Gibbon
and Frank F. Allbritten, Jr.[10] on May 6,
1953 at Thomas Jefferson University
Hospital in Philadelphia. They repaired an
atrial septal defect in an 18-year-old
woman.[11] Gibbon's machine was further
developed into a reliable instrument by a
surgical team led by John W. Kirklin at the
Mayo Clinic in Rochester, Minnesota in the
mid-1950s.[12]

The oxygenator was first conceptualized in

the 17th century by Robert Hooke and
developed into practical extracorporeal
oxygenators by French and German
experimental physiologists in the 19th
century. Bubble oxygenators have no
intervening barrier between blood and
oxygen, these are called 'direct contact'
oxygenators. Membrane oxygenators
introduce a gas-permeable membrane
between blood and oxygen that decreases
the blood trauma of direct-contact
oxygenators. Much work since the 1960s
focused on overcoming the gas exchange
handicap of the membrane barrier, leading
to the development of high-performance
microporous hollow-fibre oxygenators that
eventually replaced direct-contact
oxygenators in cardiac theatres.[13]

Components
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Cardiopulmonary bypass consists of two
main functional units, the pump and the
oxygenator which removes relatively
oxygen-depleted blood from a patient's
body and replaces it with oxygen-rich
blood through a series of tubes (hoses).

Perfusionist operating a modern heart lung machine

Tubing

The components of the CPB circuit are

interconnected by a series of tubes made
of silicone rubber or PVC.

Pumps

Roller pump

The pump console usually comprises

several rotating motor-driven pumps that
peristaltically "massage" tubing. This
action gently propels the blood through
the tubing. This is commonly referred to
as a roller pump, or peristaltic pump.
Centrifugal pump

Many CPB circuits now employ a

centrifugal pump for the maintenance and
control of blood flow during CPB. By
altering the speed of revolution (RPM) of
the pump head, blood flow is produced by
centrifugal force. This type of pumping
action is considered to be superior to the
action of the roller pump by many because
it is thought to produce less blood damage
(hemolysis, etc.), but mostly due to the
centrifugal pump being pressure limited,
therefore less likely to rupture the system
if a sudden occlusion occurs on the high-
pressure line system.
Oxygenator

The oxygenator is designed to add oxygen

to infused blood and remove some of the
carbon dioxide from the venous blood.
Cardiac surgery was made possible by
CPB using bubble oxygenators, but
membrane oxygenators have supplanted
bubble oxygenators since the 1980s. The
main reasons for this are that membrane
oxygenators tend to generate many fewer
micro-bubbles, referred to as gaseous
microemboli, which is generally
considered harmful to the patient [14] and
reduce damage to blood cells,[15]
compared to bubble oxygenators.
Another type of oxygenator gaining favour
recently is the heparin-coated blood
oxygenator which is believed to produce
less systemic inflammation and decrease
the propensity for blood to clot in the CPB
circuit.

Cannulae

Multiple cannulae are sewn into the

patient's body in a variety of locations,
depending on the type of surgery. A
venous cannula removes oxygen depleted
venous blood from a patient's body. An
arterial cannula infuses oxygen-rich blood
into the arterial system. A cardioplegia
cannula delivers a cardioplegia solution to
cause the heart to stop beating.

Some commonly used cannulation sites:

Venous Arterial Cardioplegia

Proximal aorta, distal to the cross- Proximal aorta, proximal to the cross-
Right atrium
clamp clamp

Vena cavae Femoral artery Coronary sinus (retrograde delivery)

Femoral
Axillary artery Coronary ostia
vein

Distal aorta Bypass grafts (during CABG)

Apex of the heart

Cardioplegia

A CPB circuit consists of a systemic

circuit for oxygenating blood and
reinfusing blood into a patient's body
(bypassing the heart); and a separate
circuit for infusing a solution into the heart
itself to produce cardioplegia (i.e. to stop
the heart from beating), therefore
providing myocardial protection (i.e. to
prevent the death of heart tissue).

Operation
A CPB circuit must be primed with fluid
and all air expunged from the arterial
line/cannula before connection to the
patient. The circuit is primed with a
crystalloid solution and sometimes blood
products are also added. The patient must
be fully anticoagulated with an
anticoagulant such as heparin to prevent
massive clotting of blood in the circuit.
Complications
CPB is not benign and there are a number
of associated problems:

Postperfusion syndrome (also known as

"pumphead")
Hemolysis
Capillary leak syndrome
Clotting of blood in the circuit – can
block the circuit (particularly the
oxygenator) or send a clot into the
patient.
Air embolism
Leakage – a patient can rapidly
exsanguinate (lose blood perfusion of
 tissues) if a line becomes disconnected.
1.5% of patients that undergo CPB are at
risk of developing Acute Respiratory
Distress Syndrome.

As a consequence, CPB is only used

during the several hours a cardiac surgery
may take. Most oxygenators come with a
manufacturer's recommendation that they
are only used for a maximum of 6 hours,
although they are sometimes used for up
to 10 hours, with care being taken to
ensure they do not clot off and stop
working. For longer periods than this, an
ECMO (extracorporeal membrane
oxygenation) is used, which can be in
operation for up to 31 days – such as in
this Taiwanese case, for 16 days, after
which the patient received a heart
transplant.[16]

CPB may contribute to immediate

cognitive decline. The heart-lung blood
circulation system and the connection
surgery itself release a variety of debris
into the bloodstream, including bits of
blood cells, tubing, and plaque. For
example, when surgeons clamp and
connect the aorta to tubing, resulting
emboli may block blood flow and cause
mini strokes. Other heart surgery factors
related to mental damage may be events
of hypoxia, high or low body temperature,
abnormal blood pressure, irregular heart
rhythms, and fever after surgery.[17]

References
1. McCullough, L.; Arora, S. (Dec 2004).
"Diagnosis and treatment of
hypothermia". Am Fam Physician. 70
(12): 2325–32. PMID 15617296 .
2. Lich, Bryan; Brown, Mark (2004). The
Manual of Clinical Perfusion (2nd
ed.). Fort Myers, Florida:
PERFUSION.COM, INC. p. 117.
ISBN 978-0-9753396-0-2.
3. Lich, Bryan (2004). Manual of Clinical
Pefusion (2nd ed.). Fort Myers,
Florida: perfusion.com. p. 141.
ISBN 978-0-9753396-0-2.
4. Lich, Bryan (2004). The Manual of
Clincal Perfusion (2nd ed.). Fort
myers, Florida: Perfusion.com.
p. 117. ISBN 978-0-9753396-0-2.
5. Zimmer, Heinz-Gerd (September
2003). "The heart-lung machine was
invented twice--the first time by Max
von Frey". Clinical Cardiology. 26 (9):
443–5.
doi:10.1002/clc.4960260914 .
ISSN 0160-9289 . PMID 14524605 .
6. Dennis C; Spreng DS; Nelson GE; et al.
(October 1951). "Development of a
Pump-oxygenator to Replace the
Heart and Lungs: An Apparatus
Applicable to Human Patients and
Application to One Case" . Ann. Surg.
134 (4): 709–21.
doi:10.1097/00000658-195110000-
00017 . PMC 1802968 .
PMID 14878382 .
7. Corporation, Bonnier (1 February
1951). "Popular Science" . Bonnier
Corporation. Retrieved 4 April 2018 –
via Google Books.
 8. "U of U Health - Celebrating 60 Years
of Cardiac Surgery in Utah With
Russell M. Nelson, M.D." utah.edu.
Retrieved 4 April 2018.
9. Norton, Jeffrey (2008). Surgery: Basic
science and clinical evidence. NY:
springer. p. 1473. ISBN 978-0-387-
30800-5.
10. Hedlund, Kelly D. [1] A Tribute to
Frank F. Allbritten, Jr. Origin of the
Left Ventricular Vent during the Early
Years of Open-Heart Surgery with the
Gibbon Heart-Lung Machine. Texas
Heart Institute Journal, Tex Heart Inst
 J. 2001; 28(4): 292–296. Summer
2001. Retrieved May 18, 2019.
11. Cohn LH (May 2003). "Fifty years of
open-heart surgery" . Circulation. 107
(17): 2168–70.
doi:10.1161/01.CIR.0000071746.508
76.E2 . PMID 12732590 .
12. "John Kirklin Cardiac Surgery Pioneer
Dead at Age 86 ." (April 23, 2004)
University of Alabama at
Birmingham. press release
13. Lim M (2006). "The history of
extracorporeal oxygenators".
Anaesthesia. 61 (10): 984–95.
doi:10.1111/j.1365-
 2044.2006.04781.x .
PMID 16978315 .
14. Pearson, D.T.; Holden M; Poslad S;
Murray A; Waterhouse P. (1984). "A
clinical comparison of the gas
transfer characteristics and gaseous
microemboli production of one
membrane and five bubble
oxygenators: gas transfer
characteristics and gaseous
microemboli production". Perfusion.
1 (1): 15–26.
doi:10.1177/026765918600100103 .
15. Pearson, D.T.; Holden M; Poslad S;
Murray A; Waterhouse P. (1984). "A
 clinical comparison of the gas
transfer characteristics and gaseous
microemboli production of one
membrane and five bubble
oxygenators: haemocompatibility".
Perfusion. 1 (1): 81–98.
doi:10.1177/026765918600100103 .
16. Man survives 16 days without a
heart united Press International.
April 3, 2008.
17. Stutz, Bruce "Pumphead: Does the
heart-lung machine have a dark
side?" Scientific American, January
9, 2009.

External links
Wikimedia Commons has media
related to Cardiopulmonary bypass.

International Consortium For Evidence-

Based Perfusion
CircuitSurfers: A Perfusion Blog about
Cardiopulmonary Bypass
Hessel EA, Edmunds LH (2003).
"Extracorporeal Circulation: Perfusion
Systems" . In Cohn LH, Edmunds LH
(eds.). Cardiac Surgery in the Adult. New
York: McGraw-Hill. pp. 317–38. Archived
from the original on 2006-12-10.
Retrieved 2006-12-09.
 Multimedia Manual of Cardiothoracic
Surgery. Cardiopulmonary bypass
collection.
Profiles in Science: The Clarence Dennis
Papers Selected papers of Clarence
Dennis, credited with the first attempt at
cardiopulmonary bypass surgery.

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