Objective: Closed circuit extracorporeal circulation (CCECC) has been developed to reduce deleterious effects of standard cardiopulmonary bypass (CPB). This study compares the effects of CCECC (CORx system), CPB, and off-pump coronary artery bypass grafting (OPCAB) on red blood cell damage, coagulation activation, fibrinolysis and cytokine expression. Methods: Thirty patients underwent coronary artery bypass grafting (CABG). Twenty of them were randomized into two groups: CCECC (n=10), CPB (n=10). While not randomized, OPCAB (n=10) served as a separate reference group. CCECC and CPB patients received cardioplegic arrest. Interleukin 6 (IL-6), free hemoglobin (fHb), von Willebrand factor activity (vWf), thrombin–antithrombin-III-complex (TATc), prothrombin fragment 1.2 (F 1+2) and plasmin–antiplasmin complex (PAPc) were assessed preoperatively, perioperatively and 24h postoperatively. Results: CCECC showed significantly lower red blood cell damage than CPB (fHb: CCECC, 7.1± 5.7μmol/l; CPB, 16.8±11.4μmol/l; P=0.025; OPCAB, 3.4±1.1μmol/l). Perioperatively, CCECC exhibited significantly lower activation of coagulation and fibrinolysis than CPB, but did not differ from OPCAB (vWf: CCECC, 133±52%; CPB, 241±128%; P=0.052; OPCAB, 153±58%; TATc: CCECC, 4.7±0.9ng/ml; CPB, 31.1±15.8ng/ml; P≪0.001; OPCAB, 2.4±0.6ng/ml; PAPc: CCECC, 214±30ng/ml; CPB, 897±367ng/ml; P≪0.001; OPCAB, 253±98ng/ml). In contrast, fibrinolysis markers and IL-6 were markedly increased in CCECC postoperatively (PAPc: CCECC, 458±98ng/ml; CPB, 159±128ng/ml; P≪0.001; OPCAB, 262±174ng/ml; IL-6: CCECC, 123.4±49.8pg/dl; CPB, 18.8±13.1pg/dl; P≪0.001; OPCAB, 31.6±26.2pg/dl). Conclusions: CCECC for CABG is associated with a significant reduction of red blood cell damage and activation of coagulation cascades similar to OPCAB when compared with conventional CPB while a delayed fibrinolytic and inflammatory activity was observed. These findings require further investigation to verify the promising concept of CCECC.
Heater-cooler devices (HCD) have been implicated in a cardiosurgical contamination scenario causing prosthetic valve endocarditis. We characterized contamination of new HCDs and assessed the risk of intraoperative microorganism transmission from the HCD to the operating field. We initially acquired four new FlexTherm and then four new Maquet HCU40 HCDs and assessed occurrence and speed of microbial contamination (including mycobacteria) assessing swab and water samples from the device. In parallel, we collected repeated samples from different sites in the operating room either by swab sticks or by exposing different sample plates to room air. We also reviewed microbiological results from the hospital and compared them to cardiosurgical wound infections and endocarditis cases. Finally, we simulated cardiosurgical conditions and assessed the devices' ability to expel air to the operative field. All new HCDs were clean before first use. Despite authority-mandated decontamination procedures, microbial growth (Fusarium solani, Sphingomonas paucimobilis, Pseudomonas aeruginosa, Mycobacterium chelonae, and gordonae) was identified in all HCDs over time and could not be permanently eliminated. Four of these mircoorganisms were also found in tap water. However, none of the HCD-organisms were found inside the laminar airflow operating area. Importantly, except for P. aeruginosa, none of the HCD organisms were found in patients with surgical wound infections or endocarditis. HCD-expelled air did not rise more than 40 cm above ground. HCDs cannot be expected to remain sterile despite extensive decontamination procedures. However, airborne transmission of microorganisms directly from the HCD to the operating field appears unlikely.
We report a case of a patient with severe aortic stenosis, who underwent replacement of the aortic valve as a Ross procedure. Postoperatively the patient suffered postcardiotomy failure. Despite prolonged reperfusion and other methods of circulatory support, the patient could not be weaned from cardiopulmonary bypass (CPB). Therefore, an Impella intravascular flow pump was implanted, which is technically easy and has good weaning attributes. For implantation, a vascular prosthesis was sewn to the ascending aorta and the microaxial flow pump was placed under echocardiographic guidance across the pulmonary autograft into the left ventricle. With this support, the patient could be weaned from CPB. The report evaluates the Impella microaxial hemopump as a device that is technically easy to implant with no injury to the pulmonary autograft in patients after Ross operation. Surgeons should consider the device as a short-term support in borderline indications.
Cardiogenic shock and arrest present as critical, life-threatening emergencies characterized by severely compromised tissue perfusion and inadequate oxygen supply. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) serves as a mechanical support system for patients suffering shock refractory to conventional resuscitation. Despite the utilization of VA-ECMO, clinical deterioration due to systemic inflammatory response syndrome (SIRS) resulting from the underlying shock and exposure of blood cells to the artificial surfaces of the ECMO circuit may occur. To address this issue, cytokine adsorbers offer a valuable solution by eliminating blood proteins, thereby controlling SIRS and potentially improving hemodynamics. Consequently, a prospective, randomized, blinded clinical trial will be carried out with ECMOsorb.ECMOsorb is a single-center, controlled, randomized, triple-blinded trial that will compare the hemodynamic effects of treatment with a VA-ECMO in combination with a cytokine adsorber (CytoSorb®, intervention) to treatment with VA-ECMO only (control) in patients with cardiogenic shock (with or without prior cardiopulmonary resuscitation (CPR)) requiring extracorporeal, hemodynamic support. Fifty-four patients will be randomized in a 1:1 fashion to the intervention or control group over a 36-month period. The primary endpoint of ECMOsorb is the improvement of the Inotropic Score (IS) 72 h after the intervention. Prognostic indicators, including mortality rates, hemodynamic parameters, laboratory findings, echocardiographic assessments, quality of life measurements, and clinical parameters, will serve as secondary outcome measures. The safety evaluation encompasses endpoints such as air embolisms, allergic reactions, peripheral ischemic complications, vascular complications, bleeding incidents, and stroke occurrences.The ECMOsorb trial seeks to assess the efficacy of a cytokine adsorber (CytoSorb®; CytoSorbents Europe GmbH, Berlin, Germany) in reducing SIRS and improving hemodynamics in patients with cardiogenic shock who are receiving VA-ECMO. We hypothesize that a reduction in cytokine levels can lead to faster weaning from inotropic and mechanical circulatory support, and ultimately to improved recovery.
The timely initiation of extracorporeal membrane oxygenation (ECMO) is crucial for providing life support. However, delays can occur when perfusionists are not readily available. The Jena Method aims to address this issue by offering a wet-primed ECMO system that can be rapidly established without the perfusionist's presence.
Objective: Blood gas monitoring in the extracorporeal membrane oxygenation (ECMO resp. ECLS) circuit is important for patient monitoring and a valuable guide to assess patients respiratory status. We assessed longevity and precision of an online monitoring device that is more economic and safer than individual blood gas sampling.
