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Engineering Articles
Cardiopulmonary bypass
machine - CPB
Details 8

Category: Clinical Engineering

(/articles/clinical-engineering)

Cardiopulmonary bypass can be defined as 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.

Cardiopulmonary bypass machines are operated by

perfusionists to bypass the heart and lungs during
open heart surgery. Blood returning to the heart is
diverted through a heart-lung machine (a pump-
oxygenator) before returning it to the arterial
b circulation.
c The machine does
g the work bothH of the
heart (pump blood) and the lungs (supply oxygen to
red blood cells).

The oxygenator was first conceptualised 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.   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.
The first successful open heart procedure on a
human utilizing the heart lung machine was
performed by John Gibbon on May 6, 1953 at
Thomas Jefferson University Hospital in
Philadelphia. He repaired an atrial septal defect in
an 18-year-old woman. Advances in cardiac surgery
have been possible due to the development of
cardiopulmonary bypass (CPB).

Quote from Dr Christiaan N. Barnard, the first

surgeon to carry out a successful heart transplant.

For a dying person, a transplant is not a difficult

decision.  If a lion chases you to a river filled with
crocodiles, you will leap into the water convinced
you have a chance to swim to the other side. But
you would never accept such odds if there were
no lion.

Left: A Heart-Lung Machine for coronary artery

bypass surgery.
b c g CPB is H
a form
of
extracorporeal
circulation
whose
function is
circulatory
and
respiratory
support along
with
temperature
management
to facilitate
surgery on the
heart and
great vessels. 
The CPB
pump itself is
often referred to as a heart-lung machine or "the
pump".  Cardiopulmonary bypass pumps are
operated by perfusionists in association with
surgeons who connect the pump to the patient's
body. CPB is a form of extracorporeal circulation. 
Cardiopulmonary bypass is commonly used in heart
surgery because of the difficulty of operating on the
beating heart. Operations requiring the opening of
the chambers of the heart require the use of CPB to
support the circulation during that period. The safe
conduct of CPB requires a team effort between the
surgeon, perfusionist, and anaesthesiologist.

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
b body temperature,
c permanent
g brain damage H
normally occurs in three to four minutes — death
may follow shortly afterward.

Extracorporeal membrane oxygenation (ECMO

(/articles/clinical-engineering/extracorporeal-
membrane-oxygenation-ecmo)) is a simplified form
of CPB, sometimes used as life-support for
newborns with serious birth defects, or to
oxygenate and maintain recipients for organ
transplantation until new organs can be found.

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 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 that 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 is
maintained; body temperature is usually kept at
28ºC to 32ºC (82.4-89.6ºF). 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.
b
Main
c
components
g H

Cardiopulmonary bypass consists of two main

components, the pump and the oxygenator which
remove oxygen-deprived blood from a patient's body
and replace it with oxygen-rich blood through a
series of hoses. The components of the CPB circuit
are interconnected by a series of tubes made of
silicone rubber or PVC.  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. 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 (Haemolysis, etc.).

Oxygenator: The oxygenator is designed to transfer

oxygen to infused blood and remove 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. Membrane
oxygenators consist of hollow microporous
polypropylene fibres (100–200 μm internal
diameter). Blood flows outside the fibre while gases
pass inside the fibre, thus separating the blood and
gas phases. They have lesser propensity for air
embolism and give greater accuracy in blood gas
control. Newer designs have an integrated filter to
manage emboli, thus making additional arterial
b filters unnecessary.
c Another
g type of oxygenator
H
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. A heat
exchanger is integrated with the oxygenator and
placed proximal to it to reduce the release of
gaseous emboli due to alterations in the
temperature of saturated blood.

During CPB, venous blood is drained through gravity

into a reservoir. The pump moves blood from the
reservoir to the oxygenator through a heat
exchanger, before returning it to the arterial
circulation. Additional components include suckers
(to remove blood from surgical field), vents (to
decompress the heart), haemofilters (for
ultrafiltration) and cardioplegia system. See
‘Cardiopulmonary Bypass Machine’ below.

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
deprived blood from a patient's body. An arterial
cannula is sewn into a patient's body and is used to
b infuse c
oxygen-rich blood. g
A cardioplegia cannula
H is
sewn into the heart to deliver a cardioplegia
solution to cause the heart to stop beating.

A CPB circuit consists of a systemic circuit for

oxygenating blood and re-infusing 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), and to provide myocardial protection (i.e.
to prevent death of heart tissue).  A CPB circuit
must be primed with fluid and all air expunged
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.

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. The roller pump has two rollers positioned
on a rotating arm, which compress a length of
tubing to produce forward flow. This action can
produce haemolysis and tubing debris, the
incidence of which increases with time. Hence, the
use of roller pumps for longer procedures is
discouraged. Centrifugal pump consists of
impellers/stacked cones within housing. When
rotated rapidly, negative pressure is created at one
inlet, and positive pressure at the other, thus
propelling the blood forward. They are afterload
dependent, so if the patient's systemic vascular
b resistance
c (SVR) increases,g the cardiac outputH
generated will drop unless the flow through the
pump is increased. Centrifugal pumps may improve
platelet preservation, renal function and
neurological outcomes in longer cases. For longer
periods than this, an ECMO (extra-corporeal
membrane oxygenation) or VAD (ventricular assist
device) circuit is used, which can be in operation for
up to 31 days.

Sources:

http://www.medterms.com/script/main/art.asp?
articlekey=2631
(http://www.medterms.com/script/main/art.asp?
articlekey=2631)

http://en.wikipedia.org/wiki/Cardiopulmonary_bypass
(http://en.wikipedia.org/wiki/Cardiopulmonary_bypass)
http://mybiomedical.blogspot.com/2007/08/artificial-
heart-heart-assist-devices.html
(http://mybiomedical.blogspot.com/2007/08/artificial-
heart-heart-assist-devices.html)

https://www.spectrummedical.com/quantum-
perfusion-for-the-or/quantum-technologies-for-the-
or/quantum-cbp-systems
(https://www.spectrummedical.com/quantum-
perfusion-for-the-or/quantum-technologies-for-the-
or/quantum-cbp-systems)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613602/
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613602/)

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