Cardiopulmonary

bypass
DR R SRI DEVI
ASSISTANT PROFESSOR

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 HISTORY

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 INTRODUCTION
The primary function of CPB or heart-lung (H-L) machine is to divert blood away from the heart
and lungs and return it to the systemic arterial system, thereby permitting surgery on the
nonfunctioning heart.

In doing so, it replaces the function of both the heart and the lungs.

The goal is to provide adequate gas exchange, oxygen delivery, systemic blood flow, and
arterial pressure, while minimizing the adverse effect of extracorporeal circulation.

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 COMPONENTS OF CPB
 Cannulae - venous Cardioplegia delivery system or
circuit
- arterial
Cardiotomy, field suction, cell
Venous reservoir
salvage processors and savers
The oxygenator (artificial lung or gas 
Venting
exchanging device)
Filters and bubble traps
Heat exchanger
 Safety devices and monitors on the
Systemic (arterial) pump
H–L machine
Ultrafiltration / hemoconcentrators

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 CPB CIRCUIT

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Venous cannulae : Types
A: Tapered, “two-stage” RA–IVC
cannula.

B: Straight, wire-wound “lighthouse”

tipped cannula for RA or separate
cannulation of the SVC or IVC.

C: Rightangled, metal-tipped cannula

for cannulation of the SVC or IVC.

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Venous cannulation :
Central, intra-thoracic
A: Single cannulation of RA with a “two-stage”
cavoatrial cannula.
• MC for coronary artery and aortic valve
surgery.
• The narrower tip of the cannula drains IVC.
• The wider portion, with additional drainage
holes, resides in the RA, drains blood from
the coronary sinus and SVC which enters the
RA.

B: Separate cannulation of the SVC and IVC.

• Loops placed around the cavae and venous
cannulae act as tourniquets or snares when
tightened to divert all caval flow into the
venous cannula and prevent communication
with the RA.
• Most effective at totally diverting blood away
from heart.

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Venous cannulation : Peripheral
Used for :
• minimally invasive/“port-access” approaches
• surgery via left thoracotomy
• for cannulation before entering the chest (electively or emergently)

Femoral vein cannulation:

• MC
• Cannula is positioned with the tip at the SVC–RA junction guided by TEE.
• Bicaval cannulation is possible with a special IVC cannula designed for this purpose.

Dis-advantages :
• As peripheral venous cannulae are smaller and longer than directly placed cannulae, resistance to
drainage is greater and may require use of augmented venous drainage.

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Venous drainage : Types
Gravity (siphon effect) :
Flow is influenced by central venous pressure(intravascular volume and venous
tone), height differential between the patient and the H–L machine, and
resistance in the venous cannula and tubing.
Augmented venous drainage :
(1) Vacuum-assisted drainage : vacuum (usually negative 20 to 50 mm Hg) is
applied to closed “hard-shell” venous reservoir. Increased risk of aspirating air.
(2) Kinetic-assisted drainage is accomplished by inserting a pump (usually
centrifugal, but rarely a roller pump).
“Chattering” of the venous lines suggest excessive drainage or inadequate
venous return
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Arterial cannulae :
These cannulae are the narrowest part of the circuit and carry the entire
“cardiac output”.
The size of cannula is based on
• the desired blood flow (mainly influenced by patient size)
• chosen to keep blood velocity less than 100 to 200 cm/s and pressure
gradients less than 100 mm Hg.
Higher flows and pressures result in trauma to blood elements and the vessel
wall (“sandblasting” and dissection).

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Arterial cannulae : Types
A: Tapered, bevel-tipped cannula with molded flange near
tip.

B: Angled, thin-walled, metal-tipped cannula with molded

flange for securing cannula to aorta.

C: Angled, diffusion-tipped cannula designed to direct

systemic flow in four directions to avoid a “jetting effect”
that may occur with conventional single-lumen arterial
cannulae.

D: Integral cannula/tubing connector and luer port (for

deairing).

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Arterial cannulation sites :

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Venous reservoir :
serve as a “holding tank” and act as a buffer for fluctuation and imbalances between venous
return and arterial flow.
serves as a high-capacitance (i.e., low-pressure) receiving chamber hence facilitates gravity
drainage of venous blood.
serve as a gross bubble trap for air that enters the venous line, as the site where blood, fluids,
or drugs may be added, and as a ready source of blood for transfusion into the patient.
Provides a source of blood if venous drainage is sharply reduced or stopped; this provides the
perfusionist with reaction time in order to avoid “pumping the CPB system dry” and risking
massive air embolism.
There are two classes of reservoirs:
a. Rigid hard-shell plastic, “open” venous canisters.
b. Soft-shell, collapsible plastic bag, “closed” venous reservoirs
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Systemic (arterial) pump : Roller pump
Blood is moved sequential compression of tubing by a roller
against a horseshoe-shaped backing plate or raceway.
The output is determined by the stroke volume of each revolution
(the volume within the tubing which is dependent upon the tubing
size [internal diameter] and the length of the compressed pathway
times the revolutions per minute [rpm]).
 An under-occlusive pump will allow retrograde movement of fluid.
 Over-occlusive pump will create cellular damage and release of
microparticles from tubing (“spallation”).
 If inflow is obstructed, roller pumps can generate high negative
pressures creating microbubbles (“cavitation”) and RBC damage.

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Systemic (arterial) pump : Centrifugal
pump
Contain nest of smooth plastic cones or a
vaned impeller located inside a plastic
housing.
When rotated rapidly (2,000 to3,000 rpm),
these pumps generate a pressure differential
that causes the movement of fluid.
Totally nonocclusive and afterload
dependent.
When the pump is connected to the patient’s
arterial system but is not rotating, blood will
flow backward unless the CPB systemic line is
clamped or a one-way valve is incorporated &
can cause exsanguination.

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Comparision of centrifugal vs roller
pump

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Oxygenator/Artificial lung/gas
exchanging device
Types : Bubble & Membrane oxygenators
Most commonly used is membrane oxygenators.
Positioned after the arterial pump because the resistance in the blood path
requires blood to be pumped through them.
Membrane between the ventilating gas and the flowing blood eliminating
direct contact between the blood and the gas.

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Oxygenator/Artificial lung/gas
exchanging device
Three types of membranes are used:
◦ a. True membranes (thin sheets of silicone rubber wrapped circumferentially)
◦ b. Microporous polypropylene (PPL) membranes
◦ c. Poly-methyl pentene (PMP) diffusion membranes

Arterial carbon dioxide levels are controlled by flow of freshgas (commonly

called “sweep gas flow”) through the oxygenator (comparable to alveolar
ventilation), and arterial PO2 is controlled by varying fractional inspired oxygen
(FIO2).

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Heat exchanger
Consists of heat-exchanging tubes through which the blood flows. These tubes
are surrounded by water of varying temperatures.
Excessive gradients between the blood and water temperature should be
avoided.
limit the inflow temperature of the arterial blood to 37°C and inflow
temperature of the water entering the heat exhanger to 40°C
Excessive warming can lead to gases coming out of solution and causing GME
and could cause excessive heating of the brain.

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Cardioplegia delivery system
When the aorta is cross-clamped, heart is deprived of coronary perfusion and becomes
ischemic. This is usually managed by perfusing the heart with cardioplegia solutions.
Route of delivery:
a. Aortic root: Cannula is inserted in the aortic root (proximal to the cross-clamp) has a “Y”
connector. One limb is connected to the cardioplegia delivery system and the other to suction
(to vent the left ventricle [LV] or aspirate air).
Not effective in the presence of severe AR/ when aortic root is open/ severe proximal coronary
artery stenosis.
b. Directly into the coronary ostia: done in the presence of AR or when the aortic root is open.
c. Retrograde into the coronary sinus: severe coronary artery stenosis or aortic regurgitation
and during aortic valve surgery. However, it may provide inferior protection of the RV.

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Venting
RV is readily visible and decompression depends on adequacy of venous
drainage. LV is more difficult to observe & has more adverse consequences if
distended, and requires venting.
Consequences of distention of the left heart:
◦ a. Stretches myocardium causing ventricular dysfunction
◦ b. Myocardial ischemia: Impairs subendocardial perfusion and increases myocardial oxygen
needs
◦ c. Increases left atrial pressure, leading to pulmonary edema and hemorrhage
◦ d. Interferes with surgical exposure

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Venting
Sources of blood coming into the left heart during CPB:
a. Bronchial venous drainage (normal ∼100 mL/min)
b. Systemic venous blood that bypasses venous cannulae and passes through
right heart and lungs
c. Aortic regurgitation
d. Patent ductus arteriosus (PDA) (∼1/3,500 adults)
e. Atrial septal defect (ASD), Ventricular septal defect (VSD)
Best method of evaluating the adequacy of LV decompression is TEE.

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Venting the left heart

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Ultrafiltration / Hemoconcentrators
Semipermeable membrane separates blood flowing on one side (under
pressure) and air (sometimes under vacuum) on the other side.
Water and small molecules can pass through it and removed from the blood,
but not protein or cellular components of the blood.
Raises hematocrit & removes inflammatory mediators and hence reduce the
SIRS.
Placed distal or after the arterial pump with drainage into the venous limb or
reservoir.
500 to 2,000 mL or more of fluid may be removed.
When using post-bypass (but before reversing heparin) it is referred to as
“modified ultrafiltration” or “MUF.”
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Monitors and safety devices

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Priming
ECC must be filled with fluid (“primed”) before use to eliminate all air in the circuit.
Hemodilution with reduction of hematocrit, plasma proteins (decreased oncotic pressure), and
coagulation factors.
Predicted hematocrit = (Baseline hematocrit × Estimated blood volume [EBV])/(EBV + prime
volume + first dose of crystaloid in the cardioplegia solution).
Retrograde autologous priming (RAP) : arterial blood is drained retrograde to displace
asanguineous prime in the arterial line.
Just before going on CPB, venous blood is also allowed to drain out of the patient through the
venous line into the collection bag (“antegrade autologous priming”).
Composition : balanced salt solution without glucose, colloid, heparin (2500 units/L).

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Complications
Aortic dissection Erroneous systemic blood flow
Massive air embolism Vasoplegia
Oxygenator failure Heater–cooler dysfunction
Arterial pump malfunction Electrical failure
Inadequate anticoagulation and  Gas (oxygen) supply failure
clotting of the circuit
High arterial line pressure
Dislodgment of cannulae
Distension of right and/or left heart
Obstructed venous return and air-
lock

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Risk containment :
Use of special monitoring to detect problems with venous drainage and
arterial cannulation and malperfusion.(NIRS, TEE, TCD…)
Strict adherence to protocols and following pre and immediate post bypass
checklists.
The “two-minute drill”: Wait about 2 min after going on “full bypass” and
arresting the heart, to assure that all is going well and to rule out serious
complications which can be most easily managed by discontinuing CPB before
the heart is arrested, and resuming normal circulation. One should confirm the
following endpoints:

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Risk containment :
◦ a. Able to achieve targeted flow
◦ b. Adequate venous return and not losing volume
◦ c. Adequate oxygenation from the oxygenator
◦ d. Acceptable arterial pressure and have excluded arterial dissection as the
cause of hypotension
◦ e. RV and LV are decompressed
◦ f. Acceptable systemic venous pressure
◦ g. Acceptable arterial line pressure
◦ h. Acceptable venous oxygen saturation

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Risk containment : pre-bypass checklist

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Risk containment : initial-bypass
checklist

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Pathophysiology of CPB
Major physiologic trespasses introduced by CPB include:
(i) Alterations of pulsatility, blood flow patterns, and pressure
(ii) exposure of blood to nonphysiologic surfaces and shear stresses
(iii) Hemodilution
(iv) systemic stress response and
(v) varying degrees of hypothermia (or hyperthermia during rewarming).

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Causes and contributors of adverse
systemic effects of CPB
1. Microemboli (gas and particulate matter)
2. Activation of the inflammatory and coagulation systems
3. Altered temperature, cooling and warming
4. Exposure of blood to foreign surfaces
5. Reinfusion of shed blood and transfusion of blood products
6. Hemodynamic alterations (abnormal flow rate and pattern, abnormal arterial and venous pressures)
7. Ischemia and reperfusion (especially of heart, lungs, and gut)
8. Hyperoxia
9. Hemodilution (with anemia and reduced oncotic pressure)

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Adverse events triggered by CPB

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To summarize :
The responsibility for safe CPB is shared by surgeons, anesthesiologists, and
perfusionists in order to manage cardiovascular surgery with the lowest possible
patient risk.
Anesthesiologists who provide care for patients undergoing surgery using
cardiopulmonary bypass (CPB) be intimately familiar with the function of the
heart–lung (H–L) machine.
Placing a patient on CPB is a physiologic trespass against that patient.
Absence of significant damage caused by CPB depends primarily on a particular
patient’s ability to compensate for the derangements introduced by that
trespass.

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 THANK YOU

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