30/05/2016

1

D.U. CEC « en Chirurgie cardiaque et en suppléances d’organes »

Richard SIGONNEYC.H.U. de BORDEAUX

Mercredi 18 mai 2016

RETOUR VEINEUX ACTIF

PAR SYSTÈME CINÉTIQUE M.E.C.C.?

M.E.C.C.

• Assistance respiratoire dans les pays anglo-saxons durant les années 80

• Développement de la chirurgie cardiaque à cœur battant pour pontages aorto-coronaire; assistances: droite/droite, droite/gauche

• Fin 90, équipe de l’hôpital Saint Joseph (Paris) à l’Université de Regensburg (Allemagne)

MECC: Revue de la littérature

30/05/2016

2

. Minimized extracorporeal circulation system in coronary artery bypass surgery:

a 10-year single-center experience with 2243 patients.Puehler T, Haneya A, Philipp A, Zausig YA, Kobuch R, Diez C, Birnbaum DE, Schmid C.

Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany.Eur J Cardiothorac Surg. 2010 Sep 18

MECC until now is an established concept and has become an alternative for ECC in routine CABG in our center. The use of the MECC system is associated with low mortality and

conversion rate.Excellent survival rates and low transfusion requirements in theperioperative course were achieved.

Combined coronary artery bypass grafting and aortic valve replacement with minimal extracorporeal closed circuit circulation versus standard cardiopulmonary bypass.

Yilmaz A, Sjatskig J, van Boven WJ, Waanders FG, Kelder JC, Sonker U, Kloppenburg GT.Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, P.O. Box 2500, 3430 EM Nieuwegein, The Netherlands.Interact Cardiovasc Thorac Surg. 2010 Dec.

No differences were noted in pulmonary complications, neurological events or mortality. We present for the first time data showing that combined AVR with CABG using MECC is feasible and provides better clinical results compared to standard CPB with regard to blood products requirements, without compromising operative morbidity or mortality.

The “benefits” of the mini-extracorporeal circulati on in the minimal invasive cardiac surgery eraNikolaos G. Baikoussis, MD, PhDa, , , Nikolaos A. Papakonstantinou, MDb, Efstratios Apostolakis, MD, PhDb

a Cardiac Surgery Department, Institut Mutualiste Montsouris, Paris, 75014, Franceb Cardiac Surgery Department, Ioannina University, School of Medicine, Ioannina, 45500, GreeceReceived 14 July 2013, Revised 12 October 2013, Accepted 12 December 2013, Available online 12 March 2014

Mini-extracorporeal circulation (MECC) constitutes a novel miniaturized cardiopulmonary bypass (CPB) circuit, heparin-coated and primed with aprotinin. Its membrane oxygenation is similar to conventional cardio-pulmonary bypass (CCPB), but it is a completely closed-volume system due to the lack of the venous reservoir which has been removed. In a mini circuit, the reservoir is the patient himself. Consequently, air entering the venous cannula is avoided. Nevertheless, the capabilities of MECC have been expanded either by the inclusion of a suction device that is only activated on direct contact with liquid in some circuits or by postoperative autotransfusion of the wrecked erythrocytes by a separate suction device with a cell-saver. Although the tubing diameter is similar between the two systems, the tubing length of the MECC is around half that of the CCPB, resulting in the restriction of priming volume. As a consequence, a higher hematocrit thus a limited need for perioperative blood transfusion is achieved due to less hemodilution. In addition, the inflammatory response is also diminished as a result of less artificial surface area interacting with blood. Finally, a lower dose of heparin is required prior to MECC than prior to CCPB.

ConclusionMECC circuits, despite their accompanying risks, provide a safe procedure to perform CABG, decreasing the postoperative CPB-associated morbidity thanks to the restriction of SIRS, with potential improvement in clinical outcomes. The endothelial damage, the granulocyte sequestration, and its activation are much lower since the artificial surface is smaller. Furthermore, aminiaturized circuit leads to less hemodilution and less blood loss than conventional CPB and as a result, less blood and blood products requirements. Hence, end-organs are better protected and low mortality rates are achieved when MECC is used. Therapeutic advantages of less invasive procedures have been studied by Akagi, while Osaka et al. investigated for myocardial protection the human atrial natriuretic peptide (hANP) during cardiac surgery. In conclusion, although MECC constitutes a promising alternative to CCPB preventing the drawbacks of the latter, it is not the final step of bypass technology since it still triggers inflammation.

Impact of closed minimal extracorporeal circulation on microvascular tissue perfusion during surgical aortic valve replacement: intravital imaging in a prospective randomized study Peter Donndorfa,*, Hannah Parka, Brigitte Vollmarb, Angela Almsc, Philipp Giererd, Gustav Steinhoffa and Alexander Kaminskiaa Department of Cardiac Surgery, University of Rostock, Rostock, Germanyb Institute of Experimental Surgery, University of Rostock, Rostock, Germanyc Department of Anesthesiology and Intensive Care Medicine, University of Rostock, Rostock, Germanyd Department of Trauma and Reconstructive Surgery, University of Rostock, Rostock, Germany

Interactive CardioVascular and Thoracic Surgery 19 (2014) 211–217 (publication 5 May 2014)

OBJECTIVES: Closed minimal extracorporeal circulation (MECC) systems currently do not represent the standard of surgical care for openheartsurgery. Yet, considering the beneficial results reported for coronary artery bypass graft (CABG) surgery, we used an MECC system inaortic valve replacement (AVR) and analysed the effects on intraoperative microvascular perfusion in comparison with conventional open extracorporeal circulation (CECC).

METHODS: In the current study, we analysed alterations in microvascular perfusion at 4 predefined time points (T1–T4) during surgical AVR utilizing orthogonal polarization spectral (OPS) imaging. Twenty patients were randomized for being operated on utilizing either MECC or CECC. Changes in functional capillary density (FCD, cm/cm2), mircovascular blood flow velocity (mm/s) and vessel diameter (µm) were analysed by a blinded investigator.

RESULTS: After the start of extracorporeal circulation and aortic cross-clamping (T2), both groups showed a significant drop in FCD, butwith a significantly higher FCD in the MECC group (153.1 +/- 15.0 cm/cm2 in the CECC group vs 160.8 +/- 12.2 cm/cm2 in the MECC group,P = 0.034). During the late phase of the cardiopulmonary bypass (CPB) (T3), the FCD was still significantly depressed in both treatment groups (153.5 +/- 14.6 cm/cm2 in the CECC group, P <0.05 vs ‘T1’; 159.5 +/- 12.4 cm/cm2 in the MECC group, P <0.05 versus ‘T1’). After termination of CPB (T4), the FCD recovered in both groups to baseline values. Microvascular blood flow velocity tended to remain at a higher level in the MECC group, whereas haemodilution during CPB was significantly reduced in the MECC group.

CONCLUSIONS: The use of MECC in AVR did not affect procedural safety and, resulted in beneficial preservation of microvascular blood flow velocity and significantly reduced haemodilution during CPB. In contrast to CABG surgery, the use of MECC did not improve FCD during surgical AVR. Clinical advantages possibly resulting from attenuated haemodilution and preservation of microvascular blood flow velocity require further validation in larger patient cohorts.

Minimally Invasive Extracorporeal Bypass in Minimally Invasive Heart Valve Operations: A Prospective Randomized TrialHardy Baumbach, MD, Christian J. Rustenbach, MD, Samir Ahad, MD, Ragi Nagib, MD, Marc Albert, MD, Dieter Ratge, MD, and Ulrich F. W. Franke, MD, PhDDepartments of Cardiovascular Surgery and Clinical Chemistry and Laboratory Medicine, Robert Bosch Hospital, Stuttgart, Germany

• BACKGROUND: • Minimally invasive extracorporeal circulation (MECC) is predominantly used in coronary operations. Data

supporting the benefits of MECC in minimally invasive valve operations are still absent.• METHODS: • Patients undergoing either isolated minimally invasive mitral or aortic valve procedures were prospectively

randomized to a minimally invasive group (MECC; n = 101) or a conventional extracorporeal circulation group (CECC; n = 99). The procedural and postoperative outcomes were compared, including the levels of inflammation factors (procalcitonin, interleukin [IL]-6, IL-8, and IL-10), tumor necrosis factor-α [TNF-α], and interferon-gamma [IFN-γ]).

• RESULTS: • The demographics were comparable between the groups regarding age (MECC versus CECC, 70.5 ± 10.2

years versus 73.1 ± 8.9 years; P = 0.086), left ventricular function (59.2% ± 13.4% versus 62.1% ± 14.0%; p = 0.302), EuroSCORE (7.4% ± 7.9% versus 6.8% ± 4.0%; p = 0.256), and other comorbidities. Hospital mortality (n = 1 versus n = 3; p = 0.339) and other complications were similar. However, hemoglobin level (111.9 ± 19.0 g/L versus 103.8 ± 14.6 g/L; p = 0.001), the number of packed red blood cells (PRBCs) (1.1 ±1.9 versus 1.7 ± 1.8; p = 0.003), the levels of ILs (IL-6, 194.0 ± 131.8 pg/mL versus 289.2 ± 62.5 pg/mL; p = 0.020; IL-8, 38.1 ± 27.3 pg/mL versus 45.8 ± 43.4 pg/mL; p = 0.012; IL-10, 29.0 ± 123.9 pg/mL versus 49.9 ± 85.6 pg/mL; p = 0.012), TNF-α (3.8 ± 6.7 ng/mL versus 10.8 ± 47.7 ng/mL; p = 0.049), and IFN-γ (1.9 ± 1.9 pg/mL versus 4.5 ± 2.7 pg/mL; p = 0.027) were in favor of patients in the MECC group. Additionally, those patients had shorter postoperative ventilation time (7.7 ± 8.4 hours versus 9.3 ± 12.9 hours; p = 0.010) and intensive care unit (ICU) stay (1.2 ± 1.2 days versus 2.2 ± 3.8 days; p = 0.047).

• CONCLUSIONS: • The intraprocedural data were excellent and comparable in the groups, but postoperative outcomes were

better in the MECC group. Thus MECC is preferable to CECC even for minimally invasive valve procedures. These findings strongly support a combined strategy of minimally invasive valve operations and minimally invasive extracorporeal circulation.

30/05/2016

3

DRAINAGE VEINEUX ACTIF

PAR SYSTÈME CINÉTIQUE

- RAPPELS DE DONNÉES CIRCULATOIRES

- ÉVOLUTION DU CONCEPT

- EXPÉRIENCE DU SERVICE

PLACE DE L’HÉMODYNAMIQUE ?

ANTIGOAGULATION

HÉMODYNAMIQUE

RÉACTIONINFLAMMATOIRE

y = 105,43x +

114,43

R2 = 0,994

0

50

100

150

200

250

300

350

400

450

500

550

600

0 0,5 1 1,5 2 2,5 3 3,5

heparin conc. (IU/ml)

C.E.C. DRAINAGE VEINEUX CINÉTIQUE

4 5

7

2

1

6

DRAINAGE VEINEUX ACTIF

1 - Canules veineuses 7 - Canule aortique2 - Ligne veineuse 8 - Réservoir3 - Pompe centrifuge 9 - Pompe de restitution4 - Échangeur thermique 10 - Pompe de cardioplégie5 - Échangeur gazeux 6 - Ligne artérielle

3

8

910

DRAINAGE VEINEUX

• PASSIF: gravité• ACTIF : dépression, aspiration

- transfert de volume droite/gauche

- pré charge dépendante

30/05/2016

4

AMÉLIORATION DU RETOURVEINEUX ?

GRADIENT DE PRESIION

DRAINAGE VEINEUX ACTIF

PAR POMPE CENTRIFUGE

- DIMINUTION DE L’HÉMODILUTION ?

- AMÉLIORATION DU RETOUR VEINEUX ?

- MODIFICATION DU GRADIENT DE PRESSION ?

DRAINAGE VEINEUX ACTIF

PAR POMPE CENTRIFUGE

DIMINUTION DE L’HÉMODILUTION : ≈ 30 %

→ passif : shunt 1/2 x 3/8 et réservoir

→ actif : shunt 3/8 x 3/8CANULE AORTIQUE

CANULE VEINEUSE DOUBLE ÉTAGE

CANULE DE CARDIOPLÉGIE CANULE DE DÉCHARGE GAUCHE

CANULES

LIMITES: double étage

30/05/2016

5

CANULES: évolution LIMITES: triple étage

CANULE SMARTCHOIX DE LA CANULE VEINEUSE

- TAILLE: adaptée aux besoins

- POSITIONNEMENT: obstruction du drainage veineux, peut entraîner trois problèmes principaux:

→ réduction du débit => acidose

→ hémodilution excessive =>compenser le retour

→ augmentation de la pression veineuse centrale

Régime de débit

Laminaire Turbulent

LIMITES: canule aortique

30/05/2016

6

Choix de la taille de la canule en fonction du débit

8831283

2134

2899

3840

4954

-500

500

1500

2500

3500

4500

5500

3 mm 4 mm 5 mm 6mm 7mm 8 mm

Débit maximal (l/min.)

Diamètre interne (mm)

POMPES CENTRIFUGES :TYPES

AilettesAilettes RotaflowRotaflow Vortex Vortex

OXYGÉNATEUR

TYPES DE MEMBRANES :

• Semi-perméable • À diffusion

OXYGÉNATEUR

MICROPOREUSE DIFFUSION

DRAINAGE VEINEUX ACTIF

PAR SYSTÈME CINÉTIQUE

- RÉFLEXION DE L’ÉQUIPE DU Pr X. ROQUES

- ÉVOLUTION DU CONCEPT 5 6

8

2

1

7

DRAINAGE VEINEUX ACTIF

1 - Canules veineuses 7 - Ligne artérielle2 - Ligne veineuse 8 - Canule aortique3 - Filtre piège à bulles 9 - Réservoir4 - Pompe centrifuge 10 - Pompe de restitution5 - Échangeur thermique 11 - Pompe de cardioplégie6 - Échangeur gazeux

43

910

11

30/05/2016

7

Principe rétention des bulles

- PPtB

- ∆ média filtrant

ÉVOLUTION: sécurité

DRAINAGE VEINEUX ACTIF

CONCEPT DISSOCIÉ

30/05/2016

8

CONCEPT INTÉGRÉ M.E.C.C.PRESSIONS/DÉBIT/RÉSISTANCES

Résistances = Pression artérielle moyenneIndex Cardiaque

R = PamIC

COURBE DE RETOUR VEINEUXDRAINAGE VEINEUX ACTIF

GRADIENT DE PRESSION

CA V

∆P

Q

artère veine

R = ∆P / Q

PROCÉDURESablation memb. ss.ao. faux ané.aorte asc. rvao

ablation tumeur vg fistule ao/od rvao-rvm

ané.vg-pontage dte greffe cardiaque rvao-rvp

anévrisme thoraco-abd. haller rvao-rvm-ponts.

annul.tricusp.-fermet.cia implantation thoratec rvao-plastie mitrale

annulpl. mit. - fermet.civ myxome og. rvao-plastie mitr-ponts

ao.ascendante-ponts patch él.voie sortie dte rvao-pontage

bentall plastie mit.-pontage rvm

bentall-crosse annuloplastie mitrale rvm-pontage

bi-cavo/bi-pulm. plastie triscupide rvp

c.i.a. pontages rvpadt

cav partiel pontages-carotide rvp-plastie tricuspide

civ-retension com.ao. remplacement ao. asc. syndrome du cimeterre

coarctation ross tyrone david

com.mitrale ross-kono turbine DeBakey

élarg.civ-résec.sous ao. dv-dpts-ao.ascend. vdds

DRAINAGE VEINEUX ACTIF

ET PÉDIATRIE

Fl.M.; 1 an

- 5,6 kgs – 67 cm – sc: 0,34m2

- Malposition Vx

- Coarctation

- Hypoplasie crosse aortique

- CIV

- HTAP

30/05/2016

9

SURVEILLANCE

• Hémodynamique:- p.v.c.- t.a.

• Mécanique:- canule veineuse- remplissage

DRAINAGE VEINEUX ACTIF

AVANTAGES :

- SYSTÈME CLOS- RETOUR VEINEUX- HÉMODYNAMIQUE- DÉBITS

INCONVÉNIENTS :

- ASPIRATIONS- « HABITUDES »

CONCLUSION 1

ANTIGOAGULATION

HÉMODYNAMIQUE

RÉACTIONINFLAMMATOIRE

Conclusion 2

• Diminution de l’hémodilution : exposition transfusionnelle ?

• Stabilité hémodynamique :– Diminution des drogues vasopressives– Augmentation des produits anesthésiques

• Index de pompe élevé :– Retentissement sur fonction rénale