Critical comment on the following article “Blood pumps, circuits and

cannulation techniques in cardiopulmonary bypass”

Name: Anguie Tatiana Herrera Hernandez

The main function of cardiopulmonary bypass is to divert blood from the heart and lungs to
allow cardiac surgery. It must replace the functions of the lungs (gas exchange) and the heart
(blood circulation).

Blood is drained through cannulas in the superior vena cava, inferior vena cava, or right atrium
to a pulmonary machine. From there, it is pumped through a membrane-type artificial lung
("oxygenator") back into the systemic circulation through an arterial cannula in the ascending
aorta.

In addition, other components of the circuit are needed such as the main venous and arterial
connections, the circuit includes devices such as adjustable clamps, venous reservoirs, suction
systems, cardioplegia and/or coronary perfusion delivery systems, oxygen and gas sources,
filters. , sampling ports and pressure and blood gas monitors. Safety devices such as air bubble
traps, air bubble detectors and systems to prevent retrograde flow are incorporated, as well as
pressure monitors and low level alarms in the reservoirs.

In some cases, peripheral cannulation is required where peripheral veins and arteries, such as
femoral arteries, are used for cannulation when central cannulation is not possible, such as in
aortic or minimal access surgeries.

VENOUS DRAINAGE

It is traditionally achieved by gravity siphonage, but the application of suction to venous tracts
has also been explored. Siphonage has limitations, as the venous reservoir must be below the
patient and the lines must be filled with blood to prevent air entry. The amount of drainage
depends on the pressure in the central veins, the height difference and the resistance in the
venous cannulas and connections.

Venous connection in CPB is usually achieved by inserting cannulas into the right atrium (RA).
Three basic approaches are used: bicaval (cannulas in separate SVC and IVC), single auricular,
and cavoatrial (two stages). The cavoatrial approach usually requires occlusion of the cavae to
prevent systemic venous blood from entering the right heart and to prevent air entry. The choice
of approach depends on the surgery and the specific situation.
 Types and sizes of cannulas: Venous cannulas can be single-stage or "two-stage"
(cavoauricular). They come in different sizes and are made of flexible plastic or wired to
prevent bending. The cannula size is chosen based on the required flow and the flow
characteristics of the cannula.
There is controversy over whether the type of venous cannulation affects myocardial protection
during aortic cross-clamping with cardioplegic arrest. It has been observed that cavoatrial
cannulation can provide better right heart decompression and myocardial cooling compared to
single atrial cannulation.
 Venous Air Entry: It is recognized that air can enter the venous system during CPB,
which may contribute to systemic gas microemboli (GME). This can occur around
venous cannulas and should be avoided to ensure safe operation of the system.
Peripheral venous cannulation is sometimes performed through the femoral or iliac veins for
emergency situations or specific procedures. The importance of using as large cannulas as
possible to achieve adequate flows is emphasized.
 Patent Left Superior Vena Cava (LSVC): LSVC is an anomaly that can complicate
cardiac surgery. Its presence should be considered when planning CPB, as it may
interfere with venous drainage or the delivery of retrograde cardioplegia.

ARTERIAL CANNULATION

There are various types of cannulas used for arterial cannulation, designed with different
characteristics. Some have right-angled tips, others are tapered, and some have tabs for fixation
and to avoid inserting the cannula too far into the aorta. Traditional evaluation of arterial
cannulas is based on measurement of pressure drop. An important descriptive aspect of an
arterial cannula is its "performance index", which refers to the pressure gradient as a function of
flow. The narrowest portion of the cannula in the aorta is intended to be as short as possible to
minimize the pressure gradient.
The appropriate size of the arterial cannula varies depending on the size of the patient. Small
arterial cannulas with high flow can damage the inner wall of the aorta, cause dislodgement of
particles (such as atheroemboli), and cause disturbances in flow to nearby vessels. Cannula
designs have been developed to disperse flow and reduce these detrimental effects, such as
cannulas with closed tips and multiple side holes.
 Comparison of Different Types of Cannulas: Comparative studies have been conducted
on various types of arterial cannulas to evaluate their effectiveness in terms of pressure
drop, flow patterns, and particle shedding. Some cannulas, such as expandable funnel tip
cannulas, have shown better performance in terms of lower pressure drop and less
particle shedding.
 Cobra and Aegis Dual-Flow Cannulas: Dual-flow cannulas are mentioned, such as the
"Cobra" catheter, designed to reduce cerebral embolization and allow selective brain
cooling. Although it was clinically evaluated, it has not been approved for use in the
United States. Reference is also made to the Aegis aortic cannula, a modification of the
Cobra with a single lumen, which is no longer available for clinical use.
 Embol-X Arterial Cannula with Filter: A 24F arterial cannula is described that
incorporates a side port for inserting a heparin-coated 120 µm mesh butterfly net type
 filter (Embol-X). This cannula has a higher pressure gradient and jet pressure compared
to conventional cannulas. Clinical studies evaluating its effectiveness in reducing
neurological adverse events are reported, with mixed results and lack of solid evidence of
benefit.
The choice of site for arterial cannulation is based on factors such as the type of cannula, the
planned operation, the quality of the aorta, and the surgeon's preferences. Epiaortic ultrasound
scanning is considered a useful tool to guide this selection and reduce the risk of atheroembolic
complications.

If the ascending aorta is completely calcified and rigid ("porcelain" aorta), different strategies
should be employed, such as avoiding clamping the ascending aorta, using an alternative site for
cannulation, or performing the "off-pump" operation if possible. Graft replacement of the
calcified ascending aorta is a high-risk procedure.

Before cannulation, surgeons typically make an incision in the aorta and dissect the adventitia
within the purse-string suture. The use of a partial occlusion clamp is avoided, except in pediatric
patients, to minimize trauma to the aorta. The importance of maintaining optimal blood pressure
during cannulation is highlighted. Too high or low blood pressure can increase the risk of
complications, such as tears or collapse of the aorta.

The Coanda effect is mentioned, which refers to the adhesion of a flow jet to the wall, which
may have implications for cerebral perfusion. Additionally, we warn about the possibility of
aortic dissection associated with ascending aortic cannulation, and describe the symptoms and
management of this potentially serious complication.

PERIPHERAL CANNULATION
 Femoral :
Cannulation of the femoral or iliac arteries is recommended in situations where aortic
cannulation is unsatisfactory or not feasible. This includes cases of ascending aortic aneurysms,
lack of space due to multiple ascending aortic procedures, unstable patients, prophylactic
reoperations, hemorrhagic complications during reentry, or antegrade aortic dissection.
To reduce the risk of distal ischemia when using femoral cannulation, techniques such as using a
smaller cannula to maintain blood flow to the extremity or suturing a polytetrafluoroethylene
graft to the femoral artery are mentioned.
 Abdominal aorta
 Axillary Artery
 innominate artery
 brachial arteries
 common carotid artery
 left ventricular apex
Selection of tubes and connectors:
Considerations for the selection of tubing and connectors used in extracorporeal circulation are
discussed, such as minimizing blood trauma, priming volume, and flow resistance, as well as
avoiding leaks and air aspiration. Desirable characteristics of tubes and connectors are
mentioned, such as transparency, resilience, flexibility, and kink resistance.

The arterial pump: