Coronary artery bypass grafting using a miniature right ventricular support system

Abstract

Cardiopulmonary bypass (CPB) with cardioplegic myocardial preservation has long been the gold standard for surgical care of coronary artery disease. More recently, alternatives to the conventional approach of CPB-myocardial revascularization have been developed. Epicardial stabilizing devices have been used to immobilize areas of the beating heart to provide a stable surface for some coronary anastomoses. These approaches are often limited to anterior aspects of the heart because revascularization of posterior and lateral vessels often requires the heart to be manipulated or contorted. Excessive manipulation can lead to hemodynamic compromise as a result of partially obstructing pulmonary blood flow.

A miniature extracorporeal system has been developed that uses right ventricular support and allows for epicardial surgical procedures to be conducted on a beating heart without standard CPB. The extracorporeal system consists of a coaxial atrial cannula that is connected to a miniature centrifugal pump. Blood is drained from the right atrium, passes through the miniature centrifugal pump and is delivered through the cannula’s inner reinfusion lumen into the pulmonary artery. The entire circuit volume is approximately 30 ml. The system is positioned on the sterile operative field. The pump is controlled by a console positioned adjacent to the patient. The centrifugal pump is capable of delivering blood flow at rates of 1-6 l/min. This extracorporeal system may be of benefit in maintaining adequate cardiac output during epicardial beating heart surgery.

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References

Kirklin JK. Prospects of understanding and eliminating the deleterious effects of cardiopulmonary bypass [Editorial] . Ann Thorac Surg 1991; 51: 529-531 .

Edmunds LH. Extracorporeal perfusion. In: Edmunds LH ed. Cardiac surgery in the adult. New York: McGraw Hill , 1997: 273-282.

Rinder CS. Hematologic effects of cardiopulmonary bypass. In: Gravlee GP , Davis RF , Kurusz M , Utley JR eds. Cardiopulmonary bypass: principles and practice, 2nd edn. Philadelphia, PA: Lippincott, William and Wilkins , 2000: 492-505.

Edmunds LH , Stenach N. Blood-surface interface. In: Gravlee GP , Davis RF , Kurusz M , Utley JR eds. Cardiopulmonary bypass: principles and practice, 2nd edn. Philadelphia, PA: Lippincott, William and Wilkins , 2000: 149-166.

Hornick P , Taylor KM. Immune and inflammatory responses after cardiopulmonary bypass. In: Gravlee GP , Davis RF , Kurusz M , Utley JR eds. Cardiopulmonary bypass: principles and practice, 2nd edn. Philadelphia, PA: Lippincott, William and Wilkins , 2000: 303-319.

Mack MJ. Perspectives on minimally invasive coronary artery surgery. Current assessment and future directions . Int J Cardiol 1997; 62(Suppl. I): S73-S79 .

Subramanian VA. Less invasive anterior CABG on a beating heart . Ann Thorac Surg 1997; 63(Suppl. I): S68-S71 .

Borst C , Jansen EWL , Tulleken CAF et al. Coronary artery bypass grafting without cardiopulmonary bypass and with a novel anastomosis site restraining device (‘Octopus’) . J Am Coll Cardiol 1996; 27: 1356-1364 .

Jansen EWL , Grundeman PF , Mansvelt Beck H , Heijmen RH , Borst C. Experimental off-pump grafting of a circumflex branch via sternotomy . Ann Thorac Surg 1997; 63(Suppl. I): S93-S96 .

10.

Matata BM , Sosnowski AW , Galiñanes M. Off-pump bypass graft operation significantly reduces oxidative stress and inflammation . Ann Thorac Surg 2000; 69: 785-791 .

11.

Boonstra PW , Grandjean JG , Mariani MA , Sepetka I , Taylor C. Clinical application of three new instruments in minimally invasive coronary artery bypass grafting . Cor Europaeum 1997; 6: 75-77 .

12.

Calafiore AM , Teodori G , DiGiammarco G et al. Multiple arterial conduits without cardiopulmonary bypass: early angiographic results . Ann Thorac Surg 1999; 67: 450-456 .

13.

Ascione R , Lloyd CT , Gomes WJ et al. Beating versus arrested heart revascularization: evaluation of myocardial function in a prospective randomized study . Eur J Cardiothorac Surg 1999; 15: 685-690 .

14.

Maslow A , Aronson S , Jacobsohn E , Cohn WE , Johnson RG. Off-pump coronary artery bypass graft surgery . J Cardiothorac Vasc Anesth 1999; 13: 764-781 .

15.

Grundeman PF , Borst C , van Herwaarden JA et al. Hemodynamic changes during displacement of the beating heart by the Utrecht method . Ann Thorac Surg 1997; 63(Suppl. I): S88-S92 .

16.

Geskes GG , Dekker AL , van der Veen FH et al. The enabler right ventricular circulatory support system for beating heart coronary artery bypass graft surgery . Ann Thorac Surg 1999: 68: 1558-1561 .

17.

Ascione R , Lloyd CT , Underwood MJ et al. Inflammatory response after coronary revascularization with or without cardiopulmonary bypass . Ann Thorac Surg 2000; 69: 1198-1204 .

18.

Koh TW , Carr-White GS , DeSouza AC et al. Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass . Heart 1999: 81: 495-500 .

19.

Wan S , Izzat MB , Lee TW et al. Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury . Ann Thorac Surg 1999; 68: 52-57 .

20.

Diegler A , Hirsch R , Schneider F et al. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation . Ann Thorac Surg 2000; 69: 1162-1166 .

21.

BhaskerRao B , VanHimbergen D , Edmonds HL et al. Evidence for improved cerebral function after minimally invasive bypass surgery . J Card Surg 1998; 13: 27-31 .

22.

Puskas JD , Wright CE , Ronson RS et al. Clinical outcome and angiographic patency in 125 consecutive off-pump coronary bypass patients . Heart Surg Forum 1999: 2: 216-221 .

23.

Nader ND , Khadra WZ , Reich NT et al. Blood product use in cardiac revascularization: comparison of on- and off-pump techniques . Ann Thorac Surg 1999; 68: 1640-1643 .

24.

Galletti PM , Brecher GA. Hemodynamics of total bypass. In: Galletti PM , Brecher GA eds. Heart-lung bypass: principles and techniques of extracorporeal circulation. New York: Grune and Stratton , 1962: 208-210.

25.

Matheny R , Mack M , Robbins R , Akin J. Right heart support facilitates cardiac manipulation in off-pump coronary bypass . Presented at the Society of Thoracic Surgeons Poster Session, San Antonio, Texas, January 1999.

26.

Mack M , Mullangi C , Edgarton J , Matheny R , Akin J , Mullangi C. Effect of mini-pump flow rate during right heart support for off-pump bypass . Presented at the International Society of Minimally Invasive Cardiac Surgery, Paris, France, May 1999.

27.

Edgerton J , Mullangi C , Horswell J , Akin J , Mack M. Hemodynamic changes in the displaced human heart during beating heart surgery . Presented at the Society of Thoracic Surgeons as an abstract (#41), Fort Lauderdale, Florida, January 2000.

28.

Grundeman PF , Borst C , Verlaan CWJ et al. Exposure of circumflex branches in the tilted, beating porcine heart: Echocardiographic evidence of right ventricular deformation and the effect of right or left heart bypass . J Thorac Cardiovasc Surg 1999; 118: 316-323 .

29.

Sharony R , Porat E , Nishimura Y et al. The intraaortic cannula pump: a novel assist device for the acutely failing heart . J Thorac Cardiovasc Surg 1999; 118: 924-929 .

30.

Nishimura Y , Meyns B , Ozaki S et al. The enabler cannula pump: a novel circulatory support system . Int J Artif Organs 1999: 22: 317-323 .

31.

Meyns B , Sergeant P , Siess T et al. Coronary artery bypass graft with biventricular microaxial pumps . Perfusion 1999; 14: 287-290 .

32.

Sweeney MS , Frazier OH. Device-supported myocardial revascularization: safe help for sick hearts . Ann Thorac Surg 1992; 54: 1065-1070 .

33.

Taylor LE , Adams DL , Trpkosh T , Wooten D , Wright S. RVAD/LVAD: an alternative method of circulatory support during aortocoronary bypass . Proc Am Acad Cardiovasc Perfusion 1992; 13: 43-48 .

34.

Adams DL. Emergency coronary artery bypass grafting using intra-aortic balloon pump, biventricular support and no cardioplegia following two hours of cardiopulmonary resuscitation. In: Toomasian JM , Kurusz M , Stafford T B eds. Case reports: clinical studies in extracorporeal circulation, Volume 2. Houston, TX: PREF Press , 1996: 24-30.

35.

Tassani P , Pfauder M , Richter JA , Meisner H. Bilateral extracorporeal circulation (Drew technique) for coronary artery bypass surgery using patient’s lungs as oxygenator . J Extra-Corpor Technol 1999; 31: 6-11 .

36.

Waldenberger FR , Haisjackl M , Holinski S , Lengsfeld M , Konertz W. Centrifugal pumps as left ventricular assist for coronary revascularization on a beating heart . Artif Organs 1998; 22: 698-702 .

37.

Shiiya N , Zelinsky R , Deleuze PH , Loisance DY. Changes in hemodynamics and coronary blood flow during left ventricular assistance with hemopump . Ann Thorac Surg 1992; 53: 1074-1079 .

38.

Lönn V , Peterzen B , Granfeldt H , Casimir-Ahn H. Coronary artery operation with support of the hemopump cardiac assist system . Ann Thorac Surg 1994; 58: 519-523 .