Adult Perfusion, Present and Future

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Adult Perfusion, Present and Future

• Emad Kashmiri
• KFNGH

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Adult Perfusion Present and Future

• Extracorporeal perfusion started in 1963,s
• Since that time many new medically valuable
  procedures and technologies have been developed
  and utilized by perfusionists.
• This dynamic field continues to develop and
  improve.
• perfusion as a profession.  

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• Presently in developed countries, adult cardiac
  surgery is predominately focused on the treatment
  of coronary artery disease.
• The tremendous expansion in cardiac surgery is
  closely related to the prevalence of coronary
  heart disease and the ability to apply surgical
  palliation with ever decreasing risk.  

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• Nowdays valve and Aortic surgery is not very
  common and some surgeons may only do a few cases
  a year.
• Treatments such as non-surgical (balloon)
  valvuloplasty further limit the number of
  procedures.

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• In spite of programs designed to reduce the risk
  factors for coronary heart disease,
• hypertension diet
• lack in physical exercise smoking
• obesity genetic
  factors.
• Coronary artery surgery is literally the sole
  operation that some surgeons perform in some
  centers.  

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• About 800.000 coronary bypass procedures are
  presently performed every year worldwide.

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• It has been hypothesized that elimination of the
  heart lung machine will improve morbidity and
  mortality in these high-risk patients (1) 
•  

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• However, few studies (2) reported no significant
  reduction in morbidity with their OPCABG patients
  compared to standard CABG patients. They actually
  included some advantages for the standard CABG
  patients

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• hemodynamic stability
• better blood pressure regulation
• technically superior anastomosis due to
  bloodless and motionless environment, temperature
  control
• ability to perform complete myocardial
  revascularization(a).

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• Some of the potential advantages of using OPCABG
  
• the avoidance of the aortic cross clamping
• earlier extubations
• shorter hospital stay,
• reduction in the need for blood transfusio
• lower incidence of arterial fibrillation
  decreased costs !!!!

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•       

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•  
• OPCABG disadvantages
• -The distal anastomosis - early graft occlusion
  due to increased platelet deposition at the
  anastomosis site.
• - a drop in blood pressure and cardiac output
  when the heart is elevated - resulting in
  hemodynamic instability.
• - require large volumes of intravenous fluid to
  maintain adequate arterial and pulmonary blood
  pressure.
• Trendelenburg position to augment
  ventricular filling
• administer low dose inotropes (4,5).
  

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• It is not always possible to perform complete
  revascularization due to hemodynamic instability
  or anatomy of the coronary arteries.

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• not recommended for OPCABG (a).
• intra-myocardial coronary arteries
• small coronary arteries
• inaccessible calcified coronary arteries
• disease through the length of the vessels
• with large hearts who do not tolerate
  manipulation

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•       
• New procedures which support ventricular
  function such as implanted and external
  (percutaneous) LVADs , ECMO
• artificial hearts, etc.
• will continue to provide perfusionists with a
  rich learning environment and opportunity.

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• Off pump cases now and in the future will always
  require the presence of a perfusionist that is
  fully trained and capable of dealing with the
  very demanding emergencies that can arise during
  OPCABG.

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• The level of training and experience needed for
  dealing with such emergencies will insure that
  perfusionists will continue to have a critical
  role in all adult cardiac surgical procedures.