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Stehouwer M, Legg K, Vroege RD. Can a low prime volume arterial filter be used as an alternative for a venous bubble trap in minimal extracorporeal circulation? An in vitro investigation. Perfusion 2024:2676591241256532. [PMID: 38768652 DOI: 10.1177/02676591241256532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND During cardiac surgery the use of a minimal extracorporeal circulation (MiECC) system may reduce the adverse effects for the patient. This is probably caused by reduced inflammation and hemodilution. For the use of a MiECC circuit, a venous bubble trap (VBT) is warranted for safety reasons. The aim of this study was to assess if an arterial filter with a small prime volume has the same (or better) air removal capacities as a VBT in a MiECC circuit and subsequentially may be used as an alternative. METHODS In an in vitro study, air removal properties were compared between the arterial filter and three VBT's on the market, VBT160 (Getinge), VBT 8 (LivaNova and VARD (Medtronic). In a MiECC circuit, the filter devices were placed in a venous position and challenged with massive and micro air. Gaseous microemboli (GME) were measured with a bubble counter proximal and distal of the VBT device. RESULTS More than 99.9 % of the air was removed after a bolus air challenge by all VBT's. Both the VARD and the AF100 showed better GME removal properties (not significant for the AF100) compared to the other devices. All filters showed GME generation after a challenge with massive air. Compared to the other filters, only the VARD showed no passing of larger bubbles when a volume of 50 mL of air was present in the filter. CONCLUSIONS The AF100 seems to be a safe and low prime alternative for use in a MiECC system as a venous air trap. A word of caution, placement of the AF100 arterial filter in the venous line is off label use.
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Affiliation(s)
- Marco Stehouwer
- Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein, Netherlands
| | - Kristina Legg
- Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein, Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation, Haga Hospital, Den Haag, Netherlands
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van Kaam P, Stehouwer M. Sudden pump stop may cause air release in oxygenators, ' The Hammer Effect ': An in vitro evaluation. Perfusion 2024:2676591241244961. [PMID: 38584486 DOI: 10.1177/02676591241244961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Oxygenators, as used in cardiopulmonary bypass (CPB) circuits, are components with good air removal properties. However, under some conditions the semipermeable characteristics of hollow fibers allow air to accidentally enter the blood side of the CPB circuit. This may occur when a fluid in motion is stopped suddenly by which the rapid change in momentum may cause a relative negative pressure drop, the so-called hammer effect. The hammer effect is not yet described in literature related to CPB. The aim of this in vitro study was to reproduce the hammer effect. METHODS The in vitro setup consisted of a CPB circuit with a fully occluded roller pump and one of four test oxygenators. The hammer test was performed by a sudden pump stop. The pressure wave was measured and after the test the residual air present in the oxygenator was forced into the arterial line and measured with a bubble detector. RESULTS We showed that a sudden pump stop could lead to the hammer effect, represented as a relative negative pressure drop in the arterial line. This hammer effect resulted in air release through the semipermeable fibers as we showed in two of the four tested brands of oxygenators. CONCLUSIONS We conclude that the hammer effect may occur before connection of the CPB system to the patient, and this may result in air release into the arterial blood side of the oxygenator. The hammer effect can be caused by clamping of the tubing in combination with a centrifugal pump, or by suddenly stopping the roller pump. With this study we would like to raise awareness of the hammer effect.
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Affiliation(s)
- Paul van Kaam
- Department of Extracorporeal Circulation, Sint Antonius Ziekenhuis Chirurgie, Nieuwegein, Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal Circulation, UMC Utrecht, Utrecht, Netherlands
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Ishida M, Takahashi S, Okamura H. Comparison of bubble removal performances of five membrane oxygenators with and without a pre-filter. Perfusion 2023; 38:530-538. [PMID: 35105222 DOI: 10.1177/02676591211064960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When employing minimal invasive extracorporeal circulation (MiECC), the removal of bubbles in the circuit is important to prevent air embolism. We investigated the bubble removal performance of the FHP oxygenator with a pre-filter and compared it with that of four oxygenators, including the Fusion oxygenator, Quadrox oxygenator, Inspire oxygenator, and FX oxygenator. A closed test circuit filled with an aqueous glycerin solution was used. Air injection (10 mL) was performed prior to the oxygenator, and the number and volume of the bubbles were measured at the inlet and outlet of each oxygenator. At the inlet of the five oxygenators, there were no significant differences in the total number of bubbles detected. At the outlet, bubbles were classified into two groups according to the bubble size: ≥100 μm and <100 μm. Tests were performed at pump flow rates of 4 and 5 L/min. For bubbles ≥100 μm, which are considered clinically detrimental, the FHP was the lowest number and volume of bubbles at both pump flow rates compared to the other oxygenators. Regarding the bubbles <100 μm, the number of bubbles was higher in the FHP than those in others; however, the volume of bubbles was significantly lower at 4 L/min and tended to be lower at 5 L/min. The use of the FHP with the pre-filter removed more bubbles ≥100 μm in the circuit than that by the other oxygenators.
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Affiliation(s)
- Mitsuru Ishida
- Department of Medical Engineering, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
| | - Sho Takahashi
- Department of Medical Engineering, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
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Hendrix RHJ, Debeuckelaere G, Degezelle K, Lenaerts L, Verbelen T, Weerwind PW. Clinical evaluation of the novel Capiox NX19 adult oxygenator-a multicenter study. Perfusion 2022; 38:734-739. [PMID: 35348392 PMCID: PMC10102914 DOI: 10.1177/02676591221078942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The novel Capiox NX19 adult oxygenator is, compared to its predecessors, improved with enhanced air removal technology, a polymer heat exchanger and smaller, innovative hollow fibers resulting in a surface area reduction and a lower priming volume. The aim of this study was to evaluate the NX19 oxygenator performance in a clinical setting. METHODS A prospective multicenter study was performed involving three large European university hospitals. The Capiox NX19 (n = 150) performance was assessed during adult cardiopulmonary bypass and involved gaseous microemboli handling and gas transfer efficiency. The heat exchanger performance was evaluated separately in vitro. RESULTS The heat exchanger performance factors were 0.80 ± 0.03 and 0.58 ± 0.04 at pump flow rates of 3 L/min and 6 L/min, respectively. After priming, residual post-oxygenator gaseous microemboli count and volume were decreased by 91% and 93.7%, respectively. The gas compartment pressure was 6.0 ± 2.5 mmHg, while the O2 transfer was 69 ± 30 mL/min/m2 and the CO2 transfer 73 ± 34 mL/min/m2. The O2 gradient was 44 ± 19 mmHg/LPM and the O2 diffusing capacity 0.38 ± 0.14 mL/min/mmHg. The shunt fraction was 0.19 ± 0.13, whereas oxygenator resistance and shear stress were 10.5 ± 3.7 mmHg/LPM and 5.1 ± 3.1 dyn/cm2, respectively. CONCLUSION This multicenter study displayed good clinical safety and performance of the NX19 oxygenator.
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Affiliation(s)
- Rik H J Hendrix
- Department of Cardiothoraxic Surgery, 199236Maastricht University Medical Centre, Maastricht, Netherlands
| | - Gerdy Debeuckelaere
- Department of Extra-corporeal Circulation, 60202University Hospital Antwerp, Edegem, Belgium
| | - Karlien Degezelle
- Department of Perfusion Technology, 60182University Hospitals Leuven, Leuven, Belgium
| | - Lieven Lenaerts
- Department of Perfusion Technology, 60182University Hospitals Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiac Surgery, 60182University Hospitals Leuven, Leuven, Belgium
| | - Patrick W Weerwind
- Department of Cardiothoraxic Surgery, 199236Maastricht University Medical Centre, Maastricht, Netherlands
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Yildirim F, Amanvermez Senarslan D, Yersel S, Bayram B, Taneli F, Tetik O. Systemic inflammatory response during cardiopulmonary bypass: Axial flow versus radial flow oxygenators. Int J Artif Organs 2022; 45:278-283. [PMID: 35098782 DOI: 10.1177/03913988221075043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study was to investigate the inflammatory effects of different oxygenator flow pattern types in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass. METHODS We designed this randomized, single-blind, prospective study of patients with coronary artery disease. We compared the systemic inflammatory effects of oxygenators with two types of flow: axial flow and radial flow. Therefore, we divided the patients into two groups: 24 patients in the axial group and 28 patients in the radial group. IL-1, IL-6, IL-10, and TNF-α were examined for cytokine activation leading to a systemic inflammatory reaction. The samples were collected at three different time intervals: T1, T2, and T3 (T1 was taken before cardiopulmonary bypass, T2 just 1 h after CPB onset, and T3 was taken 24 h after the surgery). RESULTS There were no significant differences in demographic characteristics between the two groups. We observed that there were notably lower levels of humoral inflammatory response parameters (IL-1, IL-6, and TNF-α) in the radial flow oxygenator group than in the axial flow group at the specific sampling times. For IL-10, there was no significant difference for any time period. CONCLUSION It might be advantageous to use a radial-flow-patterned oxygenator to limit the inflammatory response triggered by the oxygenators in cardiopulmonary bypass.
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Affiliation(s)
- Funda Yildirim
- Cardiovascular Surgery, Manisa Celal Bayar University, Manisa, Turkey
| | | | - Seyhmus Yersel
- Manisa Celal Bayar University, Manisa, Turkey.,Munich Heart Center, Munich, Germany
| | - Barıs Bayram
- Cardiovascular Surgery, Manisa Celal Bayar University, Manisa, Turkey
| | - Fatma Taneli
- Biochemistry, Manisa Celal Bayar University, Manisa, Turkey
| | - Omer Tetik
- Cardiovascular Surgery, Manisa Celal Bayar University, Manisa, Turkey
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Liu A, Sun Z, Liu Q, Zhu N, Wang S. Pumping O2 with no N2: An Overview of Hollow Fiber Membrane Oxygenators with Integrated Arterial Filters. Curr Top Med Chem 2019; 20:78-85. [PMID: 31820691 DOI: 10.2174/1568026619666191210161013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/01/2019] [Accepted: 10/20/2019] [Indexed: 11/22/2022]
Abstract
The advancement of cardiac surgery benefits from the continual technological progress of cardiopulmonary bypass (CPB). Every improvement in the CPB technology requires further clinical and laboratory tests to prove its safety and effectiveness before it can be widely used in clinical practice. In order to reduce the priming volume and eliminate a separate arterial filter in the CPB circuit, several manufacturers developed novel hollow-fiber membrane oxygenators with integrated arterial filters (IAF). Clinical and experimental studies demonstrated that an oxygenator with IAF could reduce total priming volume, blood donor exposure and gaseous microemboli delivery to the patient. It can be easily set up and managed, simplifying the CPB circuit without sacrificing safety. An oxygenator with IAF is expected to be more beneficial to the patients with low body weight and when using a minimized extracorporeal circulation system. The aim of this review manuscript was to discuss briefly the concept of integration, the current oxygenators with IAF, and the in-vitro / in-vivo performance of the oxygenators with IAF.
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Affiliation(s)
- Anxin Liu
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhiquan Sun
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qier Liu
- Biologic Sciences, College of Liberal Arts and Sciences, University of Connecticut, Storrs, CT, United States
| | - Ning Zhu
- Hunan University of Medicine, Huaihua, Hunan, China
| | - Shigang Wang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
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Stehouwer MC, de Vroege R. Air removal capacity of two different minimal invasive ECC systems: an in vitro comparison. Perfusion 2019; 34:561-567. [PMID: 30915891 DOI: 10.1177/0267659119837823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimally invasive extracorporeal circulation systems are developed to decrease the deleterious effects of cardiopulmonary bypass. For instance, prime volume and foreign surface area are decreased in these systems. However, because of the lack of a venous reservoir in minimized systems, air handling properties of these minimally invasive extracorporeal circulation systems may be decreased as compared to conventional cardiopulmonary bypass systems. The aim of this in vitro study is to compare the air handling properties of two complete minimized cardiopulmonary bypass systems of two manufacturers, of which one system is provided with the air purge control. In an in vitro study, two minimally invasive extracorporeal circulation systems, Inspire Min.I manufactured by Sorin Group Italia, Mirandola, Italy (LivaNova, London, United Kingdom) and minimized extracorporeal circulation manufactured by Maquet, Rastatt, Germany (Getinge, Germany), were challenged with two types of air challenges; a bolus air challenge and a gaseous microemboli challenge. The air removal characteristics of the venous bubble traps and of the complete minimally invasive extracorporeal circulation systems were assessed by measuring the gaseous microemboli volume and number downstream of the venous bubble traps in the arterial line with a bubble counter. No significant differences were observed in air reduction between the venous bubble traps of Getinge (venous bubble traps) and LivaNova (Inspire venous bubble traps 8 in conjunction with the air purge control). Similarly, no significant differences were observed in volume and number of gaseous microemboli in the arterial line of both complete minimally invasive extracorporeal circulation systems. However, the gaseous microemboli load of the Inspire Min.I system was marginally lower after both the bolus air and the gaseous microemboli challenges. Both minimally invasive extracorporeal circulation systems assessed in this study, the LivaNova Inspire Min.I and the Getinge minimized extracorporeal circulation, showed comparable air removal properties, after both bolus and gaseous microemboli air challenges. Besides, air purge control automatic air removal system provided with the LivaNova Inspire Min.I. system may enhance patient's safety with the use of a minimally invasive extracorporeal circulation system. We consider both systems equally safe for clinical use.
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Affiliation(s)
- Marco C Stehouwer
- Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation, HAGA Hospital, The Hague, The Netherlands
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Benstoem C, Bleilevens C, Borchard R, Stoppe C, Goetzenich A, Autschbach R, Breuer T. Retrospective Analysis of Air Handling by Contemporary Oxygenators in the Setting of Cardiac Surgery. Ann Thorac Cardiovasc Surg 2018; 24:230-237. [PMID: 29998925 PMCID: PMC6197996 DOI: 10.5761/atcs.oa.18-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Purpose: Cardiac surgery with the use of extracorporeal circulation is associated with a significant risk for gaseous microemboli (GME) despite excellent surgical techniques and highest operative standards. GME are associated with postoperative neurocognitive dysfunction and negative clinical outcome. This study determines whether oxygenator design has influence on perioperative outcome after cardiac surgery. Methods: Three different oxygenator models with integrated arterial filter (HiliteAF 7000, Fusion Affinity, and Synthesis) were retrospectively evaluated in 55 patients undergoing elective cardiac surgery with the use of extracorporeal circulation. The two-channel ultrasound bubble counter BCC200 was used to detect GME in real time. Results: All three oxygenators differ in terms of structural specifications and have different rates of number and volume GME reduction. The Fusion Affinity had the lowest arterial GME volume (1.81 µL ± 0.23 µL), which was statistically significant compared to the Synthesis (3.37 µL ± 0.71 µL, p = 0.014). However, the Synthesis had lower absolute numbers at the venous GME count (31771 µL ± 6579 µL) versus the Fusion Affinity (49304 µL ± 8196 µL). However, with regard to clinical outcome after cardiac surgery (duration of invasive and non-invasive mechanical ventilation, incidence of delirium, stroke, acute renal failure, or new myocardial infarction), we found no differences between groups. Conclusion: Despite significant differences in the design specifications, all oxygenators eliminated relevant GME volumes safely.
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Moroi M, Force M, Wang S, Kunselman AR, Ündar A. In Vitro Comparison of Pediatric Oxygenators With and Without Integrated Arterial Filters in Maintaining Optimal Hemodynamic Stability and Managing Gaseous Microemboli. Artif Organs 2018; 42:420-431. [DOI: 10.1111/aor.13090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/25/2017] [Accepted: 11/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Morgan Moroi
- Department of Pediatrics; Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital; Hershey PA USA
| | - Madison Force
- Department of Pediatrics; Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital; Hershey PA USA
| | - Shigang Wang
- Department of Pediatrics; Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital; Hershey PA USA
| | - Allen R. Kunselman
- Department of Public Health and Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine; Penn State Health Children's Hospital; Hershey PA USA
| | - Akif Ündar
- Department of Pediatrics; Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital; Hershey PA USA
- Department of Surgery, Penn State College of Medicine; Penn State Health Children's Hospital; Hershey PA USA
- Department of Bioengineering, Penn State College of Medicine; Penn State Health Children's Hospital; Hershey PA USA
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