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Minimal invasive extracorporeal circulation (MiECC) integrates the major advancements in CPB technology in one circuit, while "optimized" extracorporeal circulation circuits (opECC) use some of the illustrated components so as to upgrade conventional extracorporeal circulation (cECC). Less invasive extracorporeal circulation for performing MICS utilizes the horizontal technological advancements (grey zone) and can be considered as opECC. On the other hand, MiECC comprises full-spectrum of advancements and it is based mainly on the vertical components of CPB technology (red zone). Thus, when MICS encompasses MiECC, it utilizes the best available perfusion strategy; MICS, minimal invasive cardiac surgery.
Source publication
Development of minimally invasive cardiac surgery (MICS) served the purpose of performing surgery while avoiding the surgical stress triggered by a full median sternotomy. Minimizing surgical trauma is associated with improved cosmesis and enhanced recovery leading to reduced morbidity. However, it has to be primarily appreciated that the extracorp...
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Background
Early identification of patients at risk of AKI after cardiac surgery is of critical importance for optimizing perioperative management and improving outcomes. This study aimed to identify the association between preoperative myoglobin levels and postoperative acute kidney injury (AKI) in patients undergoing valve surgery or coronary art...
Citations
... Another significant finding from our study pertains to the optimization of ACT value, which aims to minimize the invasiveness of extracorporeal circulation. [16] In the MiECC group, the mean maximum ACT value recorded was 316±54 sec, compared to 580±127 sec in the conventional CPB group. Despite this substantial difference, neither group experienced any thromboembolic events, such as oxygenator or device-line thrombosis and stroke or transient ischemic attack, and the surgeries were safely completed. ...
Background: In this study, we shared our experience with the minimal invasive extracorporeal circulation system for coronary artery bypass grafting patients.
Methods: A total of 163 patients were included in the retrospective study, with 83 patients (63 males, 20 females; mean age: 61.9±8.9 years; range, 35 to 81 years) undergoing coronary artery bypass grafting with minimal invasive extracorporeal circulation and 80 patients (65 males, 15 females; mean age: 60.5±8.8 years; range, 43 to 82 years) undergoing coronary artery bypass grafting with conventional cardiopulmonary bypass between July 2021 and April 2023. Elective coronary bypass performed by same surgical team were included in the study. Mortality, major adverse cardiac and cerebrovascular event, hospital stays and transfusion requirements were evaluated.
Results: There were no significant differences in sex distribution, age, comorbidities, and blood values between the two groups. Intraoperatively, the minimal invasive extracorporeal circulation group had a slightly higher number of distal anastomoses and comparable times for aortic cross-clamp and cardiopulmonary bypass. Postoperative outcomes such as tamponade, bleeding, atrial fibrillation, left ventricular ejection fraction improvement or reduction, and postoperative drainage were similar between the two groups. However, the minimal invasive extracorporeal circulation group had fewer transfusions of packed red blood cells and fresh frozen plasma and a shorter length of stay in the intensive care unit.
Conclusion: The minimal invasive extracorporeal circulation system effectively preserves blood, works with lower activated clotting time values without additional complications in coronary artery bypass grafting, and could present a better option for patients with anemia or patients with a relatively high risk for high-dose heparinization.
... Integrating MiECC with Minimally Invasive Mitral Valve Surgery (MIMVS) opens new research avenues. While progress in standardizing surgical techniques is evident, challenges persist in Endo-cavitary aspiration when associating MiECC with MIMVS [1,2]. In mitral valve surgery, managing bleeding, especially from the left heart's pulmonary veins, relies on aspirators that suction blood upon air exposure. ...
The minimally invasive extracorporeal circulation (MiECC) system was developed to minimize the contact of blood with air and foreign surfaces during conventional cardiopulmonary bypass (CPB). It is also aimed to reduce the inflammatory response by further increasing the biocompatibility of the components that make up the MiECC circuits. The Minithoracotomy (MTH) approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in intensive care unit (ICU) and in hospitalization, with finally a reduction in global cost. Combining the use of the MiECC technique with minimally invasive mitral valve surgery (MIMVS) could open up new research scenarios. Although considerable progress has been made in the standardization of the surgical technique, limitations remain to be filled in the setting of Endo-cavitary aspiration for the association of MiECC with MIMVS. In this paper we introduce invention refers to a device and an air-closed endocavitary aspiration system for cardiac chamber surgery, as well as a method aimed at eliminating gaseous micro-embolic activity, hemolysis and CO 2 aspiration and alteration of carbon dioxide production (VCO 2 ) the parameters for goal directed perfusion. The system allows the surgery of the cardiac chambers to be associated with a minimally invasive extra-corporeal circulation circuit.
... Extreme hemodilution caused by large priming volumes decrease colloid osmotic pressure, resulting in the transfer of intravascular fluid to the tissue gap. The accumulation of extravascular fluid induces interstitial edema and corresponding organ dysfunction [1,2]. In addition, due to damage caused by contact between blood and the artificial material in CPB circuitry and substantial bleeding during open chest procedures, patients usually develop severe intraoperative and postoperative anemia, which is associated with increased morbidity and mortality [3]. ...
... These properties contribute to a low priming volume, an efficient blood-air interface, and a biocompatible coating system, thus attenuating hemodilution. This system reduces priming volume by approximately 30-50% and the infusion rate of different blood products by approximately 3-15%, as observed in a variety of randomized control trials [11,12], meta-analyses [1,13], and observational studies [14]. The blood conservation efficacy of MiECC was also supported by class IIa B evidence in the 2019 EACTS/EACTA/EBCP guidelines on CPB in adult cardiac surgery [10], indicating a promising platform for improving the safety of cardiac surgery. ...
Background
The adverse effects of cardiopulmonary bypass during open cardiac surgery, including hemodilution, seem to be inevitable, especially for patients who generally have a relatively lower BMI with relatively small blood volumes. This study reports the modification and use of a cardiopulmonary bypass (CPB) system to reduce priming volume and hemodilution.
Methods
This is a retrospective study of 462 adult patients who underwent cardiac valve replacement surgery from January 2019 to September 2021 at the General Hospital of Western Theater Command. The modified group consisted of 212 patients undergoing modified CPB. The control group included 250 patients receiving conventional CPB. Evaluated indices included fluid intake and output volumes during CPB, intraoperative indices related to CPB operation, usage of blood products during the peri-CPB period, and postoperative outcomes.
Results
The modified group displayed a significant reduction in the crystalloid (200 mL vs. 600 mL, P < 0.05) and colloid priming volumes (450 mL vs. 1100 mL, P < 0.05), and ultrafiltration solution volume (750 mL vs. 1200 mL, P < 0.05). Furthermore, the modified group had a significantly lower rate of defibrillation (30.2% vs. 41.2%, P < 0.05). The intraoperative urine volume (650 mL vs. 500 mL, P < 0.05) and intraoperative hematocrit (Hct) (26% vs. 24%, P < 0.05) of the modified CPB group were also higher than in the control group. The modified group required a lower infusion volume of packed red blood cells (250 mL vs. 400 mL, P < 0.05) and lower infusion rates of packed red blood cells (17.9% vs. 25.2%, P < 0.05) and fresh frozen plasma (1.41% vs. 5.2%, P < 0.05). In addition, the modified group showed significantly improved indices related to postoperative recovery.
Conclusions
The modified CPB system effectively conserves blood and shows noteworthy potential for application in cardiac valve replacement surgery.
... Considering contemporary scientific evidence and developments from industry, it has been recognized that the future of cardiac surgery lies on two main pillars; the first is minimization of surgical trauma that is accomplished with minimal invasive cardiac surgery, while the second is minimum physiologic derangement combined with maximum end-organ protection that could be achieved with surgery on MiECC. 28 For the latter, perfusion community identified a practice "gap" that prohibited application of MiECC in all cardiac surgical procedures. Though MiECC was widely adopted by many centers, especially in Europe (for coronary and aortic valve surgery), as evidenced by the number of scientific publications produced and congress presentations, technical feasibility for performing right-sided heart procedures, mitral surgery as well as high-risk and emergency aortic surgery was questioned and disallowed widespread application of this technology. ...
... 31,32 Moreover, it should be emphasized that no advancement in perfusion technology could substitute for meticulous surgical technique, which remains the cornerstone for achieving an optimal surgical outcome. 28 The surgeon as the base and a well-trained perfusionist with an actively involved anesthesiologist constitute the key-element for adopting this technology as every-day practice in cardiac surgery. Contemporary, type III MiECC circuits provide a "more physiologic" perfusion, 10 while modular configuration creates a safety "net" in case of any unexpected scenario and provides 100% technical feasibility and perfusion safety. ...
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.
Numerous extracorporeal circulation approaches are currently conducted worldwide for miniaturized cardiopulmonary bypass during heart valve surgeries. The contribution of the basis, indications, and side effects of MiCPB during heart valve surgery remains controversial despite extensive clinical and experimental research done over many years. Since the pathophysiology of the extracorporeal circulation, which is primarily related to the systemic inflammatory response, is multifactorial, the generation of inflammation is depend on blood–foreign surface interaction, where blood–air contact appears as the first trigger mechanism, and ischemia-reperfusion cascade, where inadequate tissue perfusion appears as the main trigger mechanism, especially myocardial ischemic courses. Therefore, MiCPB should address firstly to miniaturized circuit (i.e., MiECC), but also to maximized aerobic perfusion of the heart. As MiECC implementation through standard or minimal invasive surgical approaches is discussed in various chapters, this chapter will focus mostly on MiCPB concept in heart valve operations.
Introduction
Minimally invasive cardiac surgery has been evolving, with the intention of reducing surgical trauma, improve cosmesis and patient satisfaction. Single dose, crystalloid cardioplegia such as Del Nido cardioplegia and Custoidol solution have been increasingly used to reduce the interruption from repeating cardioplegia dosing to minimise the cardiopulmonary bypass and cross clamp time. However, the best cardioplegia for myocardial protection in adult minimally invasive cardiac surgery remains controversial. We aimed to conduct a meta-analysis to analyse the current evidence in the literature.
Method
A systematic review and meta-analysis was performed following the updated 2020 PRISMA guideline. Articles published in the five major electronic databases up 1st of April 2021 were identified and reviewed. The primary outcome was in-hospital or 30-day mortality. Traditional pairwise and Bayesian network meta-analyses were conducted.
Results
Nine articles were included in this study. The use of Del Nido cardioplegia was associated with a lower volume of cardioplegia used (Del Nido vs Blood, 1105.62 mL+/-123.47 vs 2569.46 mL+/-1515.52, p<0.001), cardiopulmonary bypass (Del Nido vs Custoidol vs Blood: 91.67+/−14.78 vs 138.05 +/− 21.30 vs 119.38+/−26.91 minutes, p<0.001) and cross-clamp time (Del Nido vs Custoidol vs Blood: 74.99+/−18.55 vs 82.01 +/− 17.28 vs 93.66+/−8.88 minutes, p < 0.001). No differences were observed in the incidence of in-hospital/30-day mortality rate, new onset of atrial fibrillation and stroke. Ranking analysis showed the Custoidol solution has the highest probability to be the first ranked cardioplegia.
Conclusion
No differences were found between blood and crystalloid cardioplegia in adult minimally invasive cardiac surgery in several clinical outcomes. The cardioplegia of choice in minimally invasive cardiac surgery remains the surgeons’ decision and preference.
