View source for Engineering:Cardiopulmonary bypass

{{short description|Technique that temporarily takes over the function of the heart and lungs during surgery}}{{Infobox medical intervention
|  Name        = Cardiopulmonary bypass
|  Image       = Coronary artery bypass surgery Image_657C-PH.jpg
|  Caption     = A heart–lung machine (upper right) in a [[Medicine:Coronary artery bypass surgery|coronary artery bypass surgery]].
|  ICD10       =12
|  ICD9        = {{ICD9proc|39.61}}
|  MeshID      = D002318
|  OPS301      =14
|  OtherCodes  =22570829
}}
'''Cardiopulmonary bypass''' ('''CPB''') is a technique in which a machine temporarily takes over the function of the [[Biology:Heart|heart]] and [[Medicine:Lung|lung]]s during [[Medicine:Cardiac surgery|cardiac surgery]], maintaining the circulation of blood and oxygen to the body.<ref name=Raja.9>{{cite book | vauthors = Stefanou D, Dimarakis I | veditors = Raja SG | title=Cardiac Surgery: A Complete Guide |date=2020 |publisher=Springer |location=Switzerland |isbn=978-3-030-24176-6 |pages=93–99|chapter-url=https://books.google.com/books?id=kcPPDwAAQBAJ&pg=PA93 |language=en |chapter=9. Adult cardiopulmonary bypass}}</ref> The CPB pump itself is often referred to as a '''heart-lung machine''' or "the pump". Cardiopulmonary bypass pumps are operated by [[Medicine:Perfusionist|perfusionist]]s. CPB is a form of [[Medicine:Extracorporeal|extracorporeal]] circulation. [[Engineering:Extracorporeal membrane oxygenation|Extracorporeal membrane oxygenation]] (ECMO) is generally used for longer-term treatment.

Cardiopulmonary bypass is used in many heart surgery procedures to improve safety during the surgery. The CPB machine mechanically circulates and oxygenates blood for the patient's body while bypassing the heart and lungs. A heart-lung machine is used to maintain perfusion to other body organs and tissues of the patient while the surgeon works in a bloodless surgical field. The surgeon places a [[Medicine:Cannula|cannula]] in the right atrium, vena cava, or femoral vein to withdraw blood from the body. Venous blood is drained from the body by the cannula into a reservoir and then filtered, cooled or warmed, and oxygenated before it is returned to the body by a mechanical pump. The cannula used to return oxygenated blood is usually inserted in the ascending aorta, but it can also be inserted in the femoral artery, axillary artery, or brachiocephalic artery (among others) according to the demand of the surgery.<ref name=":3">{{Cite book|title=Cardiac surgery in the adult| vauthors = Cohn LH |isbn=978-0-07-184487-1|edition=Fifth|location=New York|oclc=930496902|date = 2017-08-28}}</ref><ref name=":1" />

The person is administered [[Chemistry:Heparin|heparin]] to prevent clotting, and [[Chemistry:Protamine sulfate|protamine sulfate]] is used as a reversal drug at the end of the surgery. During the procedure, hypothermia may be maintained; body temperature is usually kept at 28&nbsp;°C to 32&nbsp;°C (82.4–89.6&nbsp;°F). 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 various crystalloid or colloidal solutions that are used to prime the bypass tubing serve to dilute the blood, prevent hemolysis and maintain electrolytic balance. Maintaining appropriate blood pressure for organs is a challenge and this is monitored carefully during the procedure.

==Uses==
[[File:Blausen 0468 Heart-Lung Machine.png|thumb|300px|Illustration of one typical way that a heart-lung machine may be connected to the veins and arteries near the heart. The three implements on the left represent (''from top to bottom'') the pump, the oxygenator, and the reservoir.]]
Cardiopulmonary bypass is commonly used in operations or surgical procedures involving the heart. The technique allows the surgical team to oxygenate and circulate the patient's blood, thus allowing the surgeon to operate safely on the heart.<ref name=":3" /> In many operations, such as [[Medicine:Coronary artery bypass surgery|coronary artery bypass grafting]] (CABG), the heart is [[Medicine:Cardioplegia|arrested]] because of the difficulty of operating on the beating heart. Operations requiring the opening of the chambers of the heart, for example, [[Medicine:Mitral valve repair|mitral valve repair]] or [[Medicine:Mitral valve replacement|replacement]], requires the use of CPB to avoid engulfing air systemically and to provide a bloodless field to increase visibility for the surgeon. The machine pumps the blood and, using an oxygenator, allows red blood cells to pick up oxygen, as well as allowing carbon dioxide levels to decrease.<ref name=":2">{{Cite book|title=TSRA Primer of Cardiothoracic Surgery| vauthors = Youssef SJ, Williams JA |publisher=TSRA/TSDA|year=2013|isbn=978-0-9894023-0-9|location=Chicago, IL}}</ref> This mimics the function of the heart and the lungs, respectively.

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 [[Medicine:Perfusion|perfusion]] (blood flow).<ref name=":3" /> If blood flow is stopped at normal body temperature, permanent [[Medicine:Brain damage|brain damage]] normally occurs in three to four minutes – death may follow shortly afterward. Similarly, CPB can be used to rewarm individuals who have [[Physics:Hypothermia|hypothermia]].<ref>{{cite journal | vauthors = McCullough L, Arora S | title = Diagnosis and treatment of hypothermia | journal = American Family Physician | volume = 70 | issue = 12 | pages = 2325–2332 | date = December 2004 | pmid = 15617296 }}</ref> This rewarming method of using CPB is successful if the core temperature of the patient is above 16&nbsp;°C.<ref name = "Lich_2004">{{cite book | vauthors = Lich B, Brown M |title=The Manual of Clinical Perfusion |publisher=perfusion.com |location=Fort Myers, Florida |isbn=978-0-9753396-0-2 |edition=2nd|year=2004 }}</ref>{{rp|117}}

[[Engineering:Extracorporeal membrane oxygenation|Extracorporeal membrane oxygenation]] (ECMO) is a simplified version of the heart lung machine that includes a [[Engineering:Centrifugal pump|centrifugal pump]] and an oxygenator to temporarily take over the function of heart and/or the lungs. Extracorporeal membrane oxygenation is useful in post cardiac surgery patients with cardiac or pulmonary dysfunction, in patients with acute pulmonary failure, massive pulmonary embolisms, lung trauma from infections, and a range of other problems that impair cardiac or pulmonary function. Extracorporeal membrane oxygenation gives the heart and/or lungs time to repair or recover but is only a temporary solution. Patients with terminal conditions, cancer, severe nervous system damage, uncontrolled [[Medicine:Sepsis|sepsis]] and other conditions may not be candidates for extracorporeal membrane oxygenation.<ref name = "Lich_2004" />{{rp|141}}

===Surgical procedures in which cardiopulmonary bypass is used===

*[[Medicine:Coronary artery bypass surgery|Coronary artery bypass surgery]]
*Cardiac valve repair and/or replacement (aortic valve, mitral valve, tricuspid valve, pulmonic valve)
*Repair of large [[Biology:Septum|septal]] defects (atrial septal defect, ventricular septal defect, atrioventricular septal defect)
*Repair and/or palliation of [[Medicine:Congenital heart defect|congenital heart defect]]s ([[Medicine:Tetralogy of Fallot|Tetralogy of Fallot]], transposition of the great vessels)
*Transplantation ([[Medicine:Heart transplantation|heart transplantation]], [[Medicine:Lung transplantation|lung transplantation]], heart–lung transplantation, [[Medicine:Liver transplantation|liver transplantation]])
*Repair of some large aneurysms ([[Medicine:Aortic aneurysm|aortic aneurysm]]s, cerebral aneurysms)
*Pulmonary thromboendarterectomy
*Pulmonary thrombectomy
*Isolated Limb perfusion<ref name = "Lich_2004" />{{rp|117}}

== Contraindications and special considerations ==
There are no absolute contraindications to cardiopulmonary bypass.<ref>{{Citation| vauthors = Ismail A, Miskolczi SY |title=Cardiopulmonary Bypass|date=2019|url=http://www.ncbi.nlm.nih.gov/books/NBK482190/|work=StatPearls|publisher=StatPearls Publishing|pmid=29489210|access-date=2020-01-21}}</ref> However, there are several factors that need to be considered by the care team when planning an operation.

Heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia and thrombosis (HITT) are potentially life-threatening conditions associated with the administration of heparin. In both of these conditions, [[Biology:Antibody|antibodies]] against heparin are formed which causes platelet activation and the formation of [[Medicine:Thrombus|blood clots]]. Because heparin is typically used in CPB, patients who are known to have the antibodies responsible for heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis require alternative forms of anticoagulation. [[Chemistry:Bivalirudin|Bivalirudin]] is the most studied heparin-alternative in people with heparin-induced thrombocytopenia and heparin-induced thrombocytopenia and thrombosis requiring CPB.<ref>{{cite journal | vauthors = Shore-Lesserson L, Baker RA, Ferraris VA, Greilich PE, Fitzgerald D, Roman P, Hammon JW | title = The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines-Anticoagulation During Cardiopulmonary Bypass | journal = The Annals of Thoracic Surgery | volume = 105 | issue = 2 | pages = 650–662 | date = February 2018 | pmid = 29362176 | doi = 10.1016/j.athoracsur.2017.09.061 | doi-access = free }}</ref>

A small percentage of patients, such as those with an [[Medicine:Antithrombin III deficiency|antithrombin III deficiency]], may exhibit resistance to heparin. In these patients, patients may need additional heparin, fresh frozen plasma, or other blood products such as recombinant anti-thrombin III to achieve adequate anticoagulation.<ref>{{cite journal | vauthors = Finley A, Greenberg C | title = Review article: heparin sensitivity and resistance: management during cardiopulmonary bypass | journal = Anesthesia and Analgesia | volume = 116 | issue = 6 | pages = 1210–1222 | date = June 2013 | pmid = 23408671 | doi = 10.1213/ANE.0b013e31827e4e62 | s2cid = 22500786 | doi-access = free }}</ref>

A [[Medicine:Persistent left superior vena cava|persistent left superior vena cava]] (PLSVC) is thoracic system variation in which the left-sided vena cava fails to involute during normal development. It is the most common variation of the thoracic venous system, occurring in approximately 0.3% of the population.<ref>{{cite journal | vauthors = Berg C, Knüppel M, Geipel A, Kohl T, Krapp M, Knöpfle G, Germer U, Hansmann M, Gembruch U | display-authors = 6 | title = Prenatal diagnosis of persistent left superior vena cava and its associated congenital anomalies | journal = Ultrasound in Obstetrics & Gynecology | volume = 27 | issue = 3 | pages = 274–280 | date = March 2006 | pmid = 16456841 | doi = 10.1002/uog.2704 | s2cid = 26364072 | doi-access = free }}</ref> The abnormality is often detected on pre-operative imaging studies, but may also be discovered intra-operatively. A persistent left superior vena cava may make it difficult to achieve proper venous drainage or deliver of retrograde [[Medicine:Cardioplegia|cardioplegia]]. Management of a persistent left superior vena cava during CPB depends on factors such as the size and drainage site of the vena cava variation.<ref name=":3" />

==Risks and complications==
{| class="wikitable"
|+ Potential complications of cardiopulmonary bypass
|-
! Complication
! Incidence <br/>(events/1000)
! Death or serious <br/>injury (%)
|-
| [[Chemistry:Protamine sulfate|Protamine reaction]]<ref name=":3" />
| 1.3
| 10.5
|-
| [[Medicine:Thrombosis|Thrombosis]]<ref name=":3" />
| 0.3–0.4
| 2.6–5.2
|-
| [[Medicine:Aortic dissection|Aortic dissection]]<ref name=":3" />
| 0.4–0.8
| 14.3–33.1
|-
| Gas embolism
| 0.2–1.3
| 0.2–8.7
|-
| Massive systemic gas embolism<ref name=":3" />
| 0.03–0.07
| 50–52
|-
| Dislodging of cannula (causing massive bleeding)<ref name=":3" />
| 0.2–1.6
| 4.2–7.1
|-
| [[Medicine:Acute respiratory distress syndrome|Acute respiratory distress syndrome]]<ref name=":3" />
| –
| –
|-
| [[Medicine:Arrhythmia|Arrythmias]]<ref name=":3" />
| –
| –
|-
| [[Medicine:Capillary leak syndrome|Capillary leak syndrome]]<ref name=":1" />
| –
| –
|-
| [[Medicine:Hemolysis|Hemolysis]]<ref name=":1" />
| –
| –
|-
| [[Medicine:Postperfusion syndrome|Postperfusion syndrome]] ("pumphead")<ref name=":1" />
| –
| –
|}
CPB is not benign and there are a number of associated problems. As a consequence, CPB is only used during the several hours a cardiac surgery may take. CPB is known to activate the coagulation cascade and stimulate inflammatory mediators, leading to hemolysis and coagulopathies. This problem worsens as complement proteins build on the membrane oxygenators.<ref name=":4" /> For this reason, most oxygenators come with a manufacturer's recommendation that they are only used for a maximum of six hours, although they are sometimes used for up to ten hours, with care being taken to ensure they do not clot off and stop working. For longer periods than this, an [[Engineering:Extracorporeal membrane oxygenation|ECMO]] (extracorporeal membrane oxygenation) is used, which can be in operation for up to 31 days – such as in a Taiwanese case, for 16 days, after which the patient received a heart transplant.<ref>[http://www.physorg.com/news126460484.html Man survives 16 days without a heart] United Press International. April 3, 2008.</ref>

The most common complication associated with CPB is a [[Chemistry:Protamine sulfate|protamine]] reaction during anticoagulation reversal.<ref name=":3" /> There are three types of protamine reactions, and each may cause life-threatening [[Medicine:Hypotension|hypotension]] (type I), [[Medicine:Anaphylaxis|anaphylaxis]] (type II), or [[Medicine:Pulmonary hypertension|pulmonary hypertension]] (type III).<ref>{{cite journal | vauthors = Nybo M, Madsen JS | title = Serious anaphylactic reactions due to protamine sulfate: a systematic literature review | journal = Basic & Clinical Pharmacology & Toxicology | volume = 103 | issue = 2 | pages = 192–196 | date = August 2008 | pmid = 18816305 | doi = 10.1111/j.1742-7843.2008.00274.x | doi-access = free }}</ref><ref name=":4">{{Cite book|title=Tsra review of cardiothoracic surgery.| vauthors = Lapar DJ |date=2016|publisher=Createspace|isbn=978-1-5232-1716-8|location=[Place of publication not identified]|oclc=953497320}}</ref>  Patients with prior exposure to protamine, such as those who have had a previous vasectomy (protamine is contained in sperm) or [[Medicine:Diabetes|diabetics]] (protamine is contained in [[Biology:NPH insulin|neutral protamine hagedorn]] (NPH) insulin formulations), are at an increased risk of type II protamine reactions due to cross-sensitivity.<ref name=":4" /> Because protamine is a fast-acting drug, it is typically given slowly to allow for monitoring of possible reactions.<ref name=":1" /> The first step in management of a protamine reaction is to immediately stop the protamine infusion. [[Biology:Corticosteroid|Corticosteroid]]s are used for all types of protamine reactions. [[Chemistry:Chlorphenamine|Chlorphenamine]] is used for type II (anaphylactic) reactions. For type III reactions, heparin is redosed and the patient may need to go back on bypass.<ref name=":4" />

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.<ref>{{cite web | vauthors = Stutz B | url = http://www.scientificamerican.com/article.cfm?id=pumphead-heart-lung-machine | title = Pumphead: Does the heart-lung machine have a dark side? | work = Scientific American | date = 9 January 2009 }}</ref>

==Components==
Cardiopulmonary bypass devices consist of two main functional units, the [[Engineering:Pump|pump]] and the [[Medicine:Oxygenator|oxygenator]] which removes relatively oxygen-depleted blood from a patient's body and replaces it with oxygen-rich blood through a series of tubes (hoses). A [[Physics:Heat exchanger|heat exchanger]] is used to control body temperature by heating or cooling the blood in the circuit. It is important that all components of the circuit are coated internally by [[Chemistry:Heparin|heparin]] or another anticoagulant to prevent clotting within the circuit.<ref name=":3" />

[[File:Perfusionist opearting heart lung machine.jpg|thumb|250px|Perfusionist operating a modern heart lung machine]]

===Tubing===
The components of the CPB circuit are interconnected by a series of tubes made of [[Chemistry:Silicone rubber|silicone rubber]] or PVC.<ref>{{Cite web|url=https://www.ebme.co.uk/articles/clinical-engineering/cardiopulmonary-bypass-machine-cpb|title=Cardiopulmonary bypass machine - CPB| vauthors = Davies H |website=www.ebme.co.uk|language=en-GB|access-date=2019-11-21}}</ref>

===Pumps===

====Centrifugal pump====
Many CPB circuits now employ a [[Engineering:Centrifugal pump|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 [[Physics:Centrifugal force|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 prevent overpressurization, clamping or kinking of lines, and produce less damage to blood products ([[Medicine:Hemolysis|hemolysis]], etc.).<ref name=":0" />

====Roller pump====
The pump console usually comprises several rotating motor-driven pumps that [[Biology:Peristalsis|peristaltically]] "massage" tubing.  This action gently propels the blood through the tubing. This is commonly referred to as a roller pump, or [[Engineering:Peristaltic pump|peristaltic pump]]. The pumps are more affordable than their centrifugal counterparts, but are susceptible to overpressurization if the lines become clamped or kinked.<ref name=":0" /> They are also more likely to cause a massive air embolism and require constant, close supervision by the perfusionist.<ref name=":3" />

===Oxygenator===
The [[Medicine:Oxygenator|oxygenator]] is designed to add [[Chemistry:Oxygen|oxygen]] to infused [[Biology:Blood|blood]] and remove some of the [[Chemistry:Carbon dioxide|carbon dioxide]] from the venous blood.  Cardiac surgery was made possible by CPB using [[Medicine:Bubble oxygenator|bubble oxygenator]]s, but [[Engineering:Membrane oxygenator|membrane oxygenator]]s have supplanted bubble oxygenators since the 1980s. The main reasons for this are that [[Engineering:Membrane oxygenator|membrane oxygenator]]s tend to generate far fewer micro-bubbles, referred to as gaseous microemboli, which is generally considered harmful to the patient and reduce damage to blood cells,<ref>{{cite journal | vauthors = Pearson DT, Holden M, Poslad S, Murray A, Waterhouse P  |title=A clinical comparison of the gas transfer characteristics and gaseous microemboli production of one membrane and five bubble oxygenators: haemocompatibility|year=1984|journal=Perfusion|volume=1|issue=1|pages=81–98|doi=10.1177/026765918600100103|s2cid=71419747}}</ref> compared to [[Medicine:Bubble oxygenator|bubble oxygenator]]s. More recently, the use of hollow-fiber oxygenators has become more widespread. These derivatives of membrane oxygenators further reduce the occurrence of microemboli by reducing the direct air-blood interface while simultaneously providing adequate gas exchange.<ref name=":0" />

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.{{Citation needed|date=January 2020}}

=== Heat exchangers ===
Because hypothermia is frequently used in CPB to reduce metabolic demands (including that of the heart), heat exchangers are implemented to warm and cool blood within the circuit. The heating and cooling is accomplished by passing the line through a warm or ice water bath. A separate heat exchanger is required for the cardioplegia line.<ref name=":3" />

===Cannulae===
Multiple [[Medicine:Cannula|cannula]]e are sewn into the patient's body in a variety of locations, depending on the type of surgery. A venous cannula removes oxygen depleted venous blood from a patient's body. An arterial cannula infuses oxygen-rich blood into the arterial system. The main determinants of cannula size selection is determined by the patient's size and weight, anticipated flow rate, and the size of the vessel being cannulated.<ref name=":3" /> A [[Medicine:Cardioplegia|cardioplegia]] cannula delivers a cardioplegia solution to cause the heart to stop beating.

Some commonly used cannulation sites:
{| class="wikitable"
|-
! Venous
! Arterial
! Cardioplegia
|-
|Right atrium
| Proximal aorta, distal to the [[Engineering:Aortic cross-clamp|cross-clamp]]
| Proximal aorta, proximal to the [[Engineering:Aortic cross-clamp|cross-clamp]]
|-
|Vena cavae
|Femoral artery
|Coronary sinus (retrograde delivery)
|-
|Femoral vein
|Axillary artery
| Coronary ostia
|-
|
| Distal aorta
| Bypass grafts (during CABG)
|-
|
| Apex of the [[Biology:Heart|heart]]
|
|-
|}

===Cardioplegia===
{{main|Medicine:Cardioplegia}}
Cardioplegia is a fluid solution used to protect the heart during CPB. It is delivered via a cannula to the opening of the coronary arteries (usually by way of the aortic root) and/or to the cardiac veins (by way of the coronary sinus).<ref name=":0" /> These delivery methods are referred to antegrade and retrograde, respectively. Cardioplegia solution protects the heart by arresting (i.e. stopping) the heart, thereby decreasing its metabolic demand. There are multiple types of cardioplegia solutions, but most work by inhibiting [[Biology:Sodium channel|fast sodium currents]] in the heart, thereby preventing conduction of the [[Biology:Action potential|action potential]]. Other types of solutions act by inhibiting calcium's actions on [[Biology:Myocyte|myocyte]]s.<ref name=":2" />

==Technique==

===Pre-operative planning===
CPB requires significant forethought before surgery. In particular, the cannulation, cooling, and cardio-protective strategies must be coordinated between the [[Social:Surgeon|surgeon]], [[Medicine:Anesthesiology|anesthesiologist]], [[Medicine:Perfusionist|perfusionist]], and [[Medicine:Nursing|nursing staff]].<ref name=":0">{{Cite book | vauthors = Mokadam NA |title=Cardiopulmonary bypass : a primer |publisher=[[Organization:University of Washington|University of Washington]] |year=2015 |oclc=922073684}}</ref>

==== Cannulation strategy ====
The cannulation strategy varies on several operation-specific and patient-specific details. The typical arterial cannulation involves the placement of a single cannulation within distal ascending aorta. The most simple form on involves placement of a single cannula (known as a dual-stage cannula) passed through the right atrium and into the inferior vena cava.

=== Intra-operative technique ===
A CPB circuit must be primed with fluid and all air expunged from the arterial line/cannula before connection to the patient. The circuit is primed with a crystalloid solution and sometimes blood products are also added. Prior to cannulation (typically after opening the pericardium when using central cannulation), [[Chemistry:Heparin|heparin]] or another [[Medicine:Anticoagulant|anticoagulant]] is administered until the activated clotting time is above 480 seconds.<ref name=":1">{{Cite book|title=Kirklin/Barratt-Boyes cardiac surgery : morphology, diagnostic criteria, natural history, techniques, results, and indications|date=2013|publisher=Elsevier/Saunders| vauthors = Kouchoukos NT, Kirklin JW |isbn=978-1-4557-4605-7|edition=4th|location=Philadelphia|oclc=812289395}}</ref>

The arterial cannulation site is inspected for [[Biology:Calcification|calcification]] or other disease. Preoperative imaging or an [[Physics:Ultrasound|ultrasound]] probe may be used to help identify aortic calcifications that could potentially become dislodged and cause an occlusion or [[Medicine:Stroke|stroke]]. Once the cannulation site has been deemed safe, two concentric, diamond-shaped pursestring sutures are placed in the distal ascending aorta. A stab incision with a [[Engineering:Scalpel|scalpel]] is made within the pursestrings and the arterial cannula is passed through the incision. It is important the cannula is passed perpendicular to the aorta to avoid creating an [[Medicine:Aortic dissection|aortic dissection]].<ref name=":1" /> The pursestrings sutures are cinched around the cannula using a tourniquet and secured to the cannula.<ref name=":0" /> At this point, the perfusionist advances the arterial line of the CPB circuit and the surgeon connects the arterial line coming from the patient to the arterial line coming from the CPB machine. Care must be taken to ensure no air is in the circuit when the two are connected, or else the patient could develop an [[Medicine:Air embolism|air embolism]].<ref name=":2" /><ref name=":1" /> Other sites for arterial cannulation include the axillary artery, brachiocephalic artery, or femoral artery.

Aside from the differences in location, [[Medicine:Vein|venous]] cannulation is performed similarly to arterial cannulation. Since calcification of the [[Medicine:Vein|venous system]] is less common, the inspection or use of an ultrasound for calcification at the cannulation sites is unnecessary. Also, because the venous system is under much less pressure than the arterial system, only a single suture is required to hold the cannula in place.<ref name=":1" /> If only a single cannula is to be used (dual-stage cannulation), it is passed through the right atrial appendage, through the tricuspid valve, and into the inferior vena cava.<ref name=":2" /> If two cannula are required (single-stage cannulation), the first one is typically passed through the superior vena cava and the second through the inferior vena cava.<ref name=":2" /> The femoral vein may also be cannulated in select patients.

If the heart must be stopped for the operation, [[Medicine:Cardioplegia|cardioplegia]] cannulas are also required. Antegrade cardioplegia (forward flowing, through the heart's arteries), retrograde cardioplegia (backwards flowing, through the heart's veins), or both types may be used depending on the operation and surgeon preference. For antegrade cardioplegia, a small incision is made in the aorta proximal to the arterial cannulation site (between the heart and arterial cannulation site) and the cannula is placed through this to deliver cardioplegia to the [[Biology:Coronary arteries|coronary arteries]]. For retrograde cardioplegia, an incision is made on the posterior (back) surface of the heart through the right ventricle. The cannula is placed in this incision, passed through the tricuspid valve, and into the coronary sinus.<ref name=":0" /><ref name=":2" /> The cardioplegia lines are connected to the CPB machine.

At this point, the patient is ready to go on bypass. Blood from the venous cannula(s) enters the CPB machine by gravity where it is oxygenated and cooled (if necessary) before returning to the body through the arterial cannula. Cardioplegia can now be administered to stop the heart, and a cross-clamp is placed across the aorta between the arterial cannula and cardioplegia cannula to prevent the arterial blood from flowing backwards into the heart. Setting appropriate blood pressure targets to maintain the health and function of the organs including the brain and kidney are important considerations.<ref>{{Cite journal |last=Kotani |first=Yuki |last2=Kataoka |first2=Yuki |last3=Izawa |first3=Junichi |last4=Fujioka |first4=Shoko |last5=Yoshida |first5=Takuo |last6=Kumasawa |first6=Junji |last7=Kwong |first7=Joey SW |date=2022-11-30 |editor-last=Cochrane Heart Group |title=High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass |url=http://doi.wiley.com/10.1002/14651858.CD013494.pub2 |journal=Cochrane Database of Systematic Reviews |language=en |volume=2022 |issue=11 |doi=10.1002/14651858.CD013494.pub2 |pmc=9709767 |pmid=36448514}}</ref>

Once the patient is ready to come off of bypass support, the cross-clamp and cannulas are removed and [[Chemistry:Protamine sulfate|protamine sulfate]] is administered to reverse the anticoagulative effects of heparin.

==History==
[[File:1955 heart lung machine.jpg|thumb|right|A heart lung machine used in London's [[Middlesex Hospital]] in 1958. Science Museum, London (2008)
]]
[[File:Cardiopulmonary bypass machine.jpg|thumb|Cardiopulmonary bypass machine used at the University of Michigan in the 1960s.]]
[[File:Patent autojektor.gif|thumb|right|Brukhonenko's ''Autojektor'']]
The Austrian-German physiologist Maximilian von Frey constructed an early prototype of a heart-lung machine in 1885 at Carl Ludwig's Physiological Institute of the University of Leipzig.<ref>{{cite journal | vauthors = Zimmer HG | title = The heart-lung machine was invented twice--the first time by Max von Frey | journal = Clinical Cardiology | volume = 26 | issue = 9 | pages = 443–445 | date = September 2003 | pmid = 14524605 | pmc = 6654655 | doi = 10.1002/clc.4960260914 }}</ref>
However, such machines were not feasible before the discovery of [[Chemistry:Heparin|heparin]] in 1916, which prevents blood coagulation. The Soviet scientist Sergei Brukhonenko developed a heart-lung machine for total body perfusion in 1926 named the ''Autojektor'', which was used in experiments with canines, some of which were showcased in the 1940 film ''Experiments in the Revival of Organisms''. A team of scientists at the [[Organization:University of Birmingham|University of Birmingham]] (including Eric Charles, a chemical engineer) were among the pioneers of this technology.<ref>{{cite journal | vauthors = Dennis C, Spreng DS, Nelson GE, Karlson KE, Nelson RM, Thomas JV, Eder WP, Varco RL | display-authors = 6 | title = Development of a pump-oxygenator to replace the heart and lungs; an apparatus applicable to human patients, and application to one case | journal = Annals of Surgery | volume = 134 | issue = 4 | pages = 709–721 | date = October 1951 | pmid = 14878382 | pmc = 1802968 | doi = 10.1097/00000658-195110000-00017 }}</ref><ref>{{cite book|url=https://archive.org/details/bub_gb_pCEDAAAAMBAJ|page=[https://archive.org/details/bub_gb_pCEDAAAAMBAJ/page/n105 4]|title=Popular Science |date=1 February 1951|publisher=Bonnier Corporation|via=Internet Archive|access-date=4 April 2018}}</ref>

Dr. Clarence Dennis led the team at the University of Minnesota Medical Center that on April 5, 1951, conducted the first human operation involving open cardiotomy with temporary mechanical takeover of both heart and lung functions. The patient did not survive due to an unexpected complex congenital heart defect. One member of the team was Dr. Russell M. Nelson, who later became president of the Church of Jesus Christ of Latter-day Saints and who performed the first open heart surgery in Utah.<ref>{{cite web|url=https://healthcare.utah.edu/publicaffairs/news/2015/Russell_Nelson_60_heart_anniversary.php|title=U of U Health - Celebrating 60 Years of Cardiac Surgery in Utah With Russell M. Nelson, M.D.|website=utah.edu|url-status=dead|archive-url=https://web.archive.org/web/20180117131234/https://healthcare.utah.edu/publicaffairs/news/2015/Russell_Nelson_60_heart_anniversary.php|archive-date=17 January 2018|access-date=4 April 2018}}</ref>

The first successful mechanical support of left ventricular function was performed on July 3, 1952, by Forest Dewey Dodrill using a machine co-developed with General Motors, the Dodrill-GMR. The machine was later used to support right ventricular function.<ref>{{cite book|title=Surgery: Basic science and clinical evidence|url=https://archive.org/details/surgerybasicscie00nort|url-access=limited| vauthors = Norton J |publisher=springer|year=2008|isbn=978-0-387-30800-5|location=NY|pages=[https://archive.org/details/surgerybasicscie00nort/page/n1473 1473]}}</ref>

The first successful open heart procedure on a human utilizing the heart lung machine was performed by John Gibbon and Frank F. Allbritten, Jr.<ref>{{cite journal | vauthors = Hedlund KD | title = A Tribute to Frank F Alibritten, Jr. Origin of the left ventricular vent during the early years of open-heart surgery with the Gibbon heart-lung machine | journal = Texas Heart Institute Journal | volume = 28 | issue = 4 | pages = 292–296 | date = 2001 | pmid = 11777154 | pmc = 101205 }}</ref> on May 6, 1953, at Thomas Jefferson University Hospital in Philadelphia. They repaired an atrial septal defect in an 18-year-old woman.<ref>{{cite journal | vauthors = Cohn LH | title = Fifty years of open-heart surgery | journal = Circulation | volume = 107 | issue = 17 | pages = 2168–2170 | date = May 2003 | pmid = 12732590 | doi = 10.1161/01.CIR.0000071746.50876.E2 | doi-access = free }}</ref> Gibbon's machine was further developed into a reliable instrument by a surgical team led by John W. Kirklin at the Mayo Clinic in Rochester, Minnesota in the mid-1950s.<ref>"[https://www.uab.edu/newsarchive/42933-john-kirklin-cardiac-surgery-pioneer-dead-at-age-86 John Kirklin Cardiac Surgery Pioneer Dead at Age 86]." (April 23, 2004) University of Alabama at Birmingham. press release</ref>

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.<ref name="Lim 2006">{{cite journal | vauthors = Lim MW | title = The history of extracorporeal oxygenators | journal = Anaesthesia | volume = 61 | issue = 10 | pages = 984–995 | date = October 2006 | pmid = 16978315 | doi = 10.1111/j.1365-2044.2006.04781.x | s2cid = 24970815 | doi-access =  }}</ref>

In 1983, Ken Litzie patented a closed emergency heart bypass system which reduced circuit and component complexity.<ref>{{Cite patent | country = US | number = 4540399 | inventor = Litzie K, Roberts CP | assign1 = C.R. Bard, Inc | assign2 = Lifestream International, LLC | url=https://patents.justia.com/patent/4540399 |title=US Patent for Emergency bypass system | gdate = 10 September 1985 | postscript = .}}</ref> This device improved patient survival after cardiac arrest because it could be rapidly deployed in non-surgical settings.<ref>{{cite journal | vauthors = Reichman RT, Joyo CI, Dembitsky WP, Griffith LD, Adamson RM, Daily PO, Overlie PA, Smith SC, Jaski BE | display-authors = 6 | title = Improved patient survival after cardiac arrest using a cardiopulmonary support system | journal = The Annals of Thoracic Surgery | volume = 49 | issue = 1 | pages = 101–105 | date = January 1990 | pmid = 2297254 | doi = 10.1016/0003-4975(90)90363-B | doi-access = free }}</ref>
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== References ==
{{reflist|30em}}

== Further reading ==
{{refbegin}}
* {{cite book |vauthors=Hessel EA, Edmunds LH |chapter=Extracorporeal Circulation: Perfusion Systems |veditors=Cohn LH, Edmunds LH |title=Cardiac Surgery in the Adult |publisher=McGraw-Hill |location=New York |year=2003 |pages=317–38 |chapter-url=http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/2/2003/317 |access-date=2006-12-09 |archive-url=https://web.archive.org/web/20061210154850/http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/2/2003/317# |archive-date=2006-12-10 |url-status=dead }}
{{refend}}

== External links ==
*[http://www.bestpracticeperfusion.org International Consortium For Evidence-Based Perfusion]
*[http://circuitsurfers.com/ CircuitSurfers: A Perfusion Blog about Cardiopulmonary Bypass]
*[https://web.archive.org/web/20111101192126/http://mmcts.ctsnetjournals.org/cgi/collection/cardiopulmonary_bypass Multimedia Manual of Cardiothoracic Surgery.  Cardiopulmonary bypass collection.]
* {{cite web | publisher = U.S. National Library of Medicine | url = http://profiles.nlm.nih.gov/ps/retrieve/Collection/CID/BX | work = Profiles in Science | title = The Clarence Dennis Papers }} credited with the first attempt at cardiopulmonary bypass surgery.

{{Cardiac surgery}}
{{Vascular procedures}}


[[Category:Medical equipment]]
[[Category:American inventions]]

{{Sourceattribution|Cardiopulmonary bypass}}