Cardiopulmonary bypass

Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of the body. 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.

Uses of cardiopulmonary bypass
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.

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.

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.

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)
 * Repair of some large aneurysms (aortic aneurysms, cerebral aneurysms)
 * Pulmonary thromboendarterectomy
 * Pulmonary thrombectomy

History
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.

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.

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.

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.

Components of cardiopulmonary bypass
Cardiopulmonary bypass consists of two main functional units, 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.

Tubing
The components of the CPB circuit are interconnected by a series of tubes made of silicone rubber or PVC.

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.).

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.

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

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), and to provide myocardial protection (i.e. to prevent death of heart tissue).

Operation
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.

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 (extra-corporeal membrane oxygenation) or VAD (ventricular assist device) circuit 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.

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.