J Extra Corpor Technol 2025, 57, 160--163 Ó The Author( s), published by EDP Sciences, 2025 https:// doi. org / 10.1051 / ject / 2025002
Available online at: ject. edpsciences. org CASE REPORT
Successful use of pulsatile flow and goal directed perfusion in a high-risk patient
Mostafa Bagherinasab( MSc) 1 and Nathaniel H. Darban( PhD, CP) 2,*
1 Extracorporeal life support, Baqiyatallah University of Medical Sciences, Sheikh Bahayi St. Mollasadra St. Vanak Square, Tehran, Iran 2 Midwestern University, 19555 N. 59th Avenue, Glendale, Arizona 85308, USA
Received 21 September 2024, Accepted 14 January 2025
Abstract – The development of multi-organ failure resulting from cardiopulmonary bypass( CPB) is acknowledged as a significant contributor to increased morbidity and mortality rates during the postoperative period. This report discusses a patient who presents with multiple comorbidities, including renal failure, reduced ejection fraction, and a history of hypertension, and is being considered for coronary artery bypass grafting( CABG) along with aortic valve replacement surgery. The administration of CPB was customized to address the unique comorbid conditions of the patient, highlighting the critical objective of maintaining an oxygen delivery index( DO 2 i) exceeding 280 mL / min / m 2, while also integrating pulsatile flow methodologies. The management of CPB, as previously discussed, resulted in a notable enhancement of kidney function, accompanied by a reduction in the patient’ s lactate levels post-surgery.
Key words: Oxygen delivery index, Cardiac index, Pulsatile flow, Organ perfusion.
Overview
Open-heart surgeries represent intricate medical interventions that entail significant risks and are linked to a wide array of possible complications after the surgery [ 1 ]. The occurrence of multi-organ failure as a consequence of CPB is recognized as a prevalent factor contributing to both morbidity and mortality in the postoperative period [ 2 ]. The idea that the modulation of pump flow should be aligned with the DO 2 i rather than depending exclusively on body surface area( BSA) and a pulse index( PI) between 1.8 and 2.4 L / min / m 2 is a widely debated subject among researchers [ 1, 3 ]. Considerable efforts have been focused on discovering methods to safeguard organs, and among these initiatives, pulsatile flow( PF) and modifications in blood flow during CPB have been recognized as important factors.
This report examines the utilization of a synergistic approach that incorporates PF alongside an enhanced CI to evaluate organ perfusion throughout the process of CPB.
Description
A 70-year-old male, a former smoker, with hypertension, and dyslipidemia presented with symptoms of dyspnea and angina. The patient required hemodialysis a decade prior to the surgical procedure, which was necessitated by a significantly reduced ejection fraction( EF) of 35 %. Cardiac catheterization
* Corresponding author: hdarban @ yahoo. com revealed triple vessel coronary artery disease and severe aortic valve insufficiency, and he was scheduled to undergo CABG and aortic valve replacement. In light of the patient’ s medical background, which includes renal failure requiring hemodialysis, advanced age, anemia, hypertension, and the expected extended duration of CPB along with aortic clamping, the perfusions’ opted to implement pulsatile flow alongside an increased CI to ensure sufficient perfusion of essential organs.
The individual presents with a height of 174 cm, a weight of 84 kg, a BSA of 2.01 m 2, a PI of 2.6 L / min / m 2, andaflow rate of 5220 mL / min / m 2, calculated using the Du Bois & Du Bois formula. The CPB system included an Inspire 8F oxygenator( LivaNova, Mirandola, Italy) and an Inspire hard-shell venous reservoir( LivaNova). The equipment comprised of a Stöckert S5 heart--lung machine with roller pump( Liva Nova) and a Stöckert Heater Cooler System 3T( LivaNova). Due to a hemoglobin level of 9 g / dL before the commencement of CPB, a priming solution consisting of 1 L of Ringer’ s solution along with 350 mL of packed red blood cells( PRBC).
Additionally, 200 mL of mannitol and albumin were included in the CPB prime. After administering heparin at a dosage of 400 IU / kg, the patient was subjected to cannulation of the aortic root, which was followed by the placement of venous bicaval cannulation. Throughout the CPB, the activated clotting time was sustained at a level greater than 480 s. The patient experienced controlled mild hypothermia during CPB, achieving a body temperature of 33 ° C. The administration of 1250 mL of Del Nido cardioplegia( DN) was performed, which
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