**4. Optimisation of the circuit and the CPB console with a holder system**

The holder system calibrates the CPB console against the ECC circuit to optimise its performance. The triangular shape of the holder system allows its remote placement of the CPB console, its distal end is near the surgeon's left hip. This has the effect of freeing up space for the different operators who are around the patient (**Figures 12** and **13**).

**4.1. Example of the circuit and the oxygenator and HSVR used**

• For a patient whose body surface is inferior or equal to 1.9 m2

with VAVD (Maquet® Cardiopulmonary GmbH, Germany)

• Membrane surface area of the oxygenator 1.3 m2

**Figure 13.** Position of the CPB console in the operating room.

• Maximum blood flow rate of the oxygenator 5 l/min

• Oxygenator Quadrox—I Small Adult (Maquet® Cardiopulmonary GmbH, Germany)

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• Surface coating Bioline the oxygenator of the circuit of the ECC and the compatible HSVR

Alternative 1

• Flow index: 2.4/min/m2

The concept of the CPB console with a holder system, has given us the possibility of reducing the lengths of lines of aspirations of +/−50%. The length of the arterial line of 3/8 in is +/− 100 cm (from the output of the arterial filter of the oxygenator up to the connection of the arterial cannula). Furthermore, the length of the venous line of 3/8 in is also +/− 100 cm (from the venous cannula up to the connection of the HSVR inlet). Therefore, there is a massive reduction of the air/blood surface, blood/contact materials, the dead space of the system and the priming volume (as a reminder: 100 cm of tubing 3/8 in contains 68 ml of liquid). All the dead spaces of the circuit are reduced to a minimum and it is very easy to perform an autologous priming retrograde (RAP) without any significant variation in the patient's volemia, including arterial line, arterial filter and antegrade autologous priming of the venous line (VAP) before the start of CPB [11] (**Figures 12**–**14**).

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**Figure 13.** Position of the CPB console in the operating room.

#### **4.1. Example of the circuit and the oxygenator and HSVR used**

#### Alternative 1

**4. Optimisation of the circuit and the CPB console with a holder** 

the different operators who are around the patient (**Figures 12** and **13**).

(VAP) before the start of CPB [11] (**Figures 12**–**14**).

**Figure 12.** CPB console with the holder system, top view.

158 Advances in Extra-corporeal Perfusion Therapies

The holder system calibrates the CPB console against the ECC circuit to optimise its performance. The triangular shape of the holder system allows its remote placement of the CPB console, its distal end is near the surgeon's left hip. This has the effect of freeing up space for

The concept of the CPB console with a holder system, has given us the possibility of reducing the lengths of lines of aspirations of +/−50%. The length of the arterial line of 3/8 in is +/− 100 cm (from the output of the arterial filter of the oxygenator up to the connection of the arterial cannula). Furthermore, the length of the venous line of 3/8 in is also +/− 100 cm (from the venous cannula up to the connection of the HSVR inlet). Therefore, there is a massive reduction of the air/blood surface, blood/contact materials, the dead space of the system and the priming volume (as a reminder: 100 cm of tubing 3/8 in contains 68 ml of liquid). All the dead spaces of the circuit are reduced to a minimum and it is very easy to perform an autologous priming retrograde (RAP) without any significant variation in the patient's volemia, including arterial line, arterial filter and antegrade autologous priming of the venous line

**system**


• Flow index: 2.4 l/min/m2

• Level detector on the HSVR

• Flow index: 2.4 l/min/m2

• Level detector on the HSVR

Alternative 3

• Oxygenator INSPIRE 6 FM (LivaNova® Mirandola, Italy)

patible HSVR with VAVD (LivaNova® Mirandola, Italy)

• Surface coating Phosphorylcholine the oxygenator of the circuit of the ECC and the com-

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• Retrograde autologous priming (RAP), including arterial line, arterial filter and antegrade

• Residual priming or hemodilution of the patient at the start of ECC = 300 ml

• Oxygenator Quadrox—I Adult (Maquet® Cardiopulmonary GmbH, Germany)

• Surface coating Bioline the oxygenator of the circuit of the ECC and the compatible HSVR

• Retrograde autologous priming (RAP), including arterial line, arterial filter and antegrade

We routinely use the VAVD system with venous cannulas that are chosen according to their hemodynamic characteristics (design, size, internal-external diameter, pressure drop, etc.). The atrio-caval venous cannulae of reduced diameter have the disadvantage of slipping into the inferior vena cava during the surgical intervention and necessitate a greater negative pressure in the HSVR by the VAVD system. It is important to choose an armed venous cannula in a diameter adapted to the right atrium and a central cage that eliminates the phenomenon of massive suction of the right atrial wall. Venous cannulae with orifices of the central cage of

• Residual priming or hemodilution of the patient at the start of ECC = 300 ml

• Membrane surface area of the oxygenator 1.4 m2

• VAVD system and arterial/venous line 3/8 in

autologous priming of the venous line (VAP)

• For a patient whose body surface is superior to 2.5 m2

• Membrane surface area of the oxygenator 1.8 m2

• VAVD system and arterial/venous line 3/8 in

autologous priming of the venous line (VAP)

• Maximum blood flow rate of the oxygenator 7 l/min

with VAVD (Maquet® Cardiopulmonary GmbH, Germany)

• Maximum blood flow rate of the oxygenator 6 l/min

**Figure 14.** ECC circuit for adult patients with the holder system.


#### Alternative 2

• For a patient whose body surface is superior to 1.9 m2


#### Alternative 3

• VAVD system and arterial /venous line 3/8 in

**Figure 14.** ECC circuit for adult patients with the holder system.

autologous priming of the venous line (VAP)

• For a patient whose body surface is superior to 1.9 m2

• Retrograde autologous priming (RAP), including arterial line, arterial filter and antegrade

• Residual priming or hemodilution of the patient at the start of ECC = 250 ml

• Level detector on the HSVR

160 Advances in Extra-corporeal Perfusion Therapies

Alternative 2


We routinely use the VAVD system with venous cannulas that are chosen according to their hemodynamic characteristics (design, size, internal-external diameter, pressure drop, etc.). The atrio-caval venous cannulae of reduced diameter have the disadvantage of slipping into the inferior vena cava during the surgical intervention and necessitate a greater negative pressure in the HSVR by the VAVD system. It is important to choose an armed venous cannula in a diameter adapted to the right atrium and a central cage that eliminates the phenomenon of massive suction of the right atrial wall. Venous cannulae with orifices of the central cage of sufficiently large size offset each other considerably reduce the incidence of this phenomenon of chattering (**Figure 15**).

patient. As the ECC becomes an arteriovenous extension of the patient's vascular network, the arterial flow and venous flow of the ECC must be in equilibrium. This constant ensures an adequate arteriovenous systemic flow capable of satisfying the patient's physiological

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Reducing the surface area contact of air/blood, blood/materials, the dead space of the system and the balance of arteriovenous flow results in a reduction of the risk of abdominal stasis and its repercussions on tissue perfusion. This ensures stability of the patient's blood volume that is in the HSVR. This optimisation of the hemodynamic equilibrium gives the possibility to widen the range of the strategies which are used during the management of the patients who undergo surgery under ECC (reduction of hemodilution, transfusions,

In order to limit the area contact of air/blood, blood/materials during ECC, the excess blood volume in the HSVR is isolated in biocompatible transfer bags. If necessary, it is re-infused to the patient during or at the end of the ECC. In general, the hematic volume in our HSVR

The shape of the lower part of the HSVR that we use is conical or cylindrical, this has the consequence of limiting the free contact surface of the blood with the air and the biomaterials

which constitute the base part of the HSVR (wall, filters, etc.) [23] (**Figures 15**).

needs during ECC [18–22].

during ECC is 350 to 400 ml.

**Figure 16.** CPB console with the holder system, top view.

etc.).

With an appropriate venous cannula and a venous line of 3/8 in diameter, the vacuum required in the HSVR achieved by the VAVD system needs to simply replace the vacuum generated by venous drainage by gravity in a venous line of 1/2 in diameter, taking into account the internal pre-gravity of the HSVR from the right atrium of the patient to the lower part of the HSVR.

For example, for a systemic flow of 4.5–5 l/min with a venous cannula of 33–43 Fr (TF3343O Edwards®, USA) and a venous line of 3/8 in diameter, the vacuum necessary by the VAVD system is −20 to −25 mmHg (**Figure 15**).

In order to have a precise control of the VAVD system, we placed on the venous line of 3/8 in a monitoring of the negative and positive pressure. This triggers an alarm if the values reach −40 mmHg or + 3 mmHg. The VAVD system (Maquet® Cardiopulmonary GmbH, Germany) has internal safeguards that protects the HSVR from pressures above +3 mmHg and below −100 mmHg. Before each ECC intervention, we check the correct calibration of our roller pumps (**Figures 12**, **13**, and **15**).

The optimisation of venous return with VAVD is conditioned by the optimal choice of the venous cannula and its positioning; it improves the hemodynamics of the ECC and the

**Figure 15.** Venous cannulae.

patient. As the ECC becomes an arteriovenous extension of the patient's vascular network, the arterial flow and venous flow of the ECC must be in equilibrium. This constant ensures an adequate arteriovenous systemic flow capable of satisfying the patient's physiological needs during ECC [18–22].

sufficiently large size offset each other considerably reduce the incidence of this phenomenon

With an appropriate venous cannula and a venous line of 3/8 in diameter, the vacuum required in the HSVR achieved by the VAVD system needs to simply replace the vacuum generated by venous drainage by gravity in a venous line of 1/2 in diameter, taking into account the internal pre-gravity of the HSVR from the right atrium of the patient to the lower

For example, for a systemic flow of 4.5–5 l/min with a venous cannula of 33–43 Fr (TF3343O Edwards®, USA) and a venous line of 3/8 in diameter, the vacuum necessary by the VAVD

In order to have a precise control of the VAVD system, we placed on the venous line of 3/8 in a monitoring of the negative and positive pressure. This triggers an alarm if the values reach −40 mmHg or + 3 mmHg. The VAVD system (Maquet® Cardiopulmonary GmbH, Germany) has internal safeguards that protects the HSVR from pressures above +3 mmHg and below −100 mmHg. Before each ECC intervention, we check the correct calibration of our roller

The optimisation of venous return with VAVD is conditioned by the optimal choice of the venous cannula and its positioning; it improves the hemodynamics of the ECC and the

of chattering (**Figure 15**).

162 Advances in Extra-corporeal Perfusion Therapies

system is −20 to −25 mmHg (**Figure 15**).

pumps (**Figures 12**, **13**, and **15**).

**Figure 15.** Venous cannulae.

part of the HSVR.

Reducing the surface area contact of air/blood, blood/materials, the dead space of the system and the balance of arteriovenous flow results in a reduction of the risk of abdominal stasis and its repercussions on tissue perfusion. This ensures stability of the patient's blood volume that is in the HSVR. This optimisation of the hemodynamic equilibrium gives the possibility to widen the range of the strategies which are used during the management of the patients who undergo surgery under ECC (reduction of hemodilution, transfusions, etc.).

In order to limit the area contact of air/blood, blood/materials during ECC, the excess blood volume in the HSVR is isolated in biocompatible transfer bags. If necessary, it is re-infused to the patient during or at the end of the ECC. In general, the hematic volume in our HSVR during ECC is 350 to 400 ml.

The shape of the lower part of the HSVR that we use is conical or cylindrical, this has the consequence of limiting the free contact surface of the blood with the air and the biomaterials which constitute the base part of the HSVR (wall, filters, etc.) [23] (**Figures 15**).

**Figure 16.** CPB console with the holder system, top view.
