Minimized extracorporeal circulation in non-coronary surgery

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

Modular minimally invasive extracorporeal circulation ensures perfusion safety and technical feasibility in cardiac surgery; a systematic review of the literature

INTRODUCTION

Despite extensive evidence that shows clinical of superiority of MiECC, worldwide penetration remains low due to concerns regarding air handling and volume management in the context of a closed system. The purpose of this study is to thoroughly investigate perfusion safety and technical feasibility of performing all cardiac surgical procedures with modular (hybrid) MiECC, as experienced from the perfusionist's perspective.

METHODS

We retrospectively reviewed perfusion charts of consecutive adult patients undergoing all types of elective, urgent, and emergency cardiac surgery under modular MiECC. The primary outcome measure was perfusion safety and technical feasibility, as evidenced in the need for conversion from a closed to an open circuit. A systematic review of the literature was conducted aiming to ultimately clarify whether there are any safety issues regarding MiECC technology.

RESULTS

We challenged modular MiECC use in a series of 403 consecutive patients of whom a significant proportion (111/403; 28%) underwent complex surgery including reoperations (4%), emergency repair of acute type A aortic dissection and composite aortic surgery (1.7%). Technical success rate was 100%. Conversion to an open circuit was required in 18/396 patients (4.5%), excluding procedures performed under circulatory arrest. Open configuration accounted for 40% ± 21% of total procedural perfusion time and was related to significant hemodilution and increase in peak lactate levels. Systematic review revealed that safety of the procedure challenged originated from a single report, while no clinical adverse event related to MiECC was identified.

CONCLUSIONS

Use of modular MiECC secures safety and ensures technical feasibility in all cardiac surgical procedures. It represents a type III active closed system, while its stand-by component is reserved for a small (<5%) proportion of procedures and for a partial procedural time. Thus, it eliminates any safety concern regarding air handling and volume management, while it overcomes any unexpected intraoperative scenario.