Cardiopulmonary Bypass

Abdelhadi Ismail; George Semien; Sanjeev Sharma; Sara A. Collier; Szabolcs Y. Miskolczi.

Author Information and Affiliations

Last Update: August 12, 2024.

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Continuing Education Activity

Cardiopulmonary bypass (CPB) is a critical technology in cardiac surgery, allowing for the
temporary replacement of the heart and lung functions during intricate surgical procedures. The
CPB circuit, or heart-lung machine, diverts venous blood from the patient, oxygenates and filters
it, and then returns it to the arterial system, ensuring continuous perfusion of vital organs while
the heart is stopped. This process involves various components, including venous and arterial
cannulas, oxygenators, heat exchangers, and pumps, and requires meticulous coordination and
precise control to maintain patient stability and prevent complications.
By participating in this course, clinicians enhance their competence in managing CPB
procedures by comprehensively understanding its mechanics and components. They gain skills in
operating and troubleshooting CPB equipment, optimizing patient safety, and improving
outcomes through effective interprofessional communication and coordination. The course also
covers preoperative planning, intraoperative management, and postoperative care strategies,
enabling clinicians to deliver high-quality, patient-centered care in cardiac surgery settings.
Objectives:
 Identify appropriate candidates for cardiopulmonary bypass based on surgical indications
and patient characteristics.
 Differentiate between venous and arterial cannulation techniques for cardiopulmonary
bypass initiation.
 Assess cardiopulmonary bypass circuit function and patient response during bypass,
including monitoring vital signs and blood gases.
 Collaborate and communicate effectively with the interprofessional healthcare team,
including anesthesia providers and surgical team members, to optimize perioperative care
and patient outcomes.
Access free multiple choice questions on this topic.
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Introduction
Cardiopulmonary bypass (CPB) is a crucial technology in modern cardiac surgery that answered
one of the toughest questions in the history of medicine: Can we operate on human hearts
without causing mortality to the patient? Early heart surgeries were limited to conditions deemed
safe for operation, such as minor tears of the pericardium, heart, and vessels, or extracardiac
congenital conditions like coarctation of the aorta and patent ductus arteriosus. The revolutionary
breakthrough in cardiac surgery included the development of CPB—a procedure that stops the
heart, allowing surgeons to create a bloodless field and providing a motionless environment for
intricate procedures while continuing to maintain essential blood flow and oxygenation to the
body's organs.[1][2][3][4]
The CPB circuit includes a pump to circulate blood and an oxygenator to exchange oxygen and
carbon dioxide, replicating the physiological processes of the heart and lungs. Since its inception
in the mid-twentieth century, CPB has enabled complex heart surgeries, including coronary
artery bypass grafting, valve replacements, and congenital heart defect corrections. Continuous
advancements in CPB technology have enhanced safety, reduced complications, and improved
patient outcomes. However, the procedure carries risks, such as inflammatory responses,
coagulopathies, and potential organ dysfunction, necessitating careful management and
coordination among the surgical team, perfusionists, anesthesiologists, and nursing staff.
Understanding the principles, techniques, and advancements in CPB is essential for all healthcare
professionals involved in cardiac surgery, as it directly impacts the success of surgical
interventions and patient recovery.
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Anatomy and Physiology

CPB is multifaceted in cardiac surgery, involving several critical functions to support the
patient's cardiovascular system during surgical procedures. First, CPB facilitates emptying the
heart by draining blood through venous cannulas, allowing the surgical team to operate on a
bloodless field. The blood is then oxygenated outside the body using pump oxygenators,
temporarily taking over the lung's role in oxygenation.[5] Additionally, CPB includes
mechanisms to adjust the blood's chemical composition and electrolyte levels via a reservoir
container and regulates its temperature using a heat exchanger machine.
Furthermore, CPB returns the oxygenated blood to the patient's circulation through arterial
cannulas, ensuring continuous perfusion of vital organs. Additionally, it collects and salvages
blood lost during surgery using cardiotomy suckers, thereby minimizing the need for blood
transfusions. CPB systems often incorporate cardiac vents to prevent heart enlargement during
surgery by maintaining optimal cardiac pressures. CPB can deliver cardioplegia—a specialized
solution that induces temporary cardiac arrest to protect myocardial tissue during delicate
procedures. CPB setups include adjuncts and standby pathways within a closed circuit driven by
pumps and interconnected by tubing to enhance safety, ensuring the patient's stability and
viability throughout the surgical intervention.
Understanding CPB's anatomy and physiology involves recognizing its impact on the body's
inflammatory response. Research indicates that CPB triggers a systemic inflammatory response
syndrome due to several factors. Blood coming into contact with the artificial surfaces of the
CPB circuit initiates a cascade of events involving complement activation, leukocyte activation,
and endothelial cell dysfunction. Surgical trauma, endotoxemia (due to gut-derived toxins
entering the bloodstream during surgery), blood loss, and ischemia-reperfusion injury further
exacerbate this response. These processes collectively lead to the release of pro-inflammatory
cytokines, reactive oxygen species, and nitric oxide, contributing to oxidative stress.[6] Elevated
oxidative stress during CPB is associated with increased postoperative morbidity and mortality
rates.
Clinicians must know these physiological responses to mitigate potential complications.
Strategies to minimize inflammatory responses and blood loss include using biocompatible CPB
circuits, administering anti-inflammatory agents, optimizing surgical techniques for reducing
trauma, and maintaining meticulous hemostasis. Understanding the intricate balance between
achieving effective cardiac surgery and managing CPB-induced physiological responses is
crucial for improving patient outcomes in cardiac surgery.
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Indications
CPB is indicated in cardiac surgery when procedures require temporary cessation of the heart's
function and bypassing of the heart and lungs to facilitate surgical repair. The primary
indications for CPB include:
 Coronary artery bypass graft
o CPB is commonly used during coronary artery bypass graft surgery to bypass
blocked coronary arteries with grafts (usually veins or arteries from elsewhere in
the body) to restore blood flow to the heart muscle.
 Valve replacement or repair
o CPB is necessary for repairing or replacing heart valves affected by stenosis or
regurgitation.
 Congenital heart defects
o Children and adults born with congenital heart defects, such as septal defects or
complex structural abnormalities, may require CPB for corrective surgeries.
 Aortic aneurysm repair
o Surgical repair of aneurysms involving the aorta often involves CPB to maintain
blood flow while repairing the weakened artery wall.
 Cardiac tumor removal
o CPB may be used during surgical removal procedures in benign or malignant
tumors affecting the heart.
 Heart transplantation
o CPB supports the circulation during heart transplant surgeries, allowing for the
removal of the diseased heart and its replacement with a healthy donor heart.
The decision to use CPB depends on the specific surgical procedure and the patient's overall
health status. By using CPB, surgeons can work on the heart while maintaining adequate
oxygenation and circulation throughout the body, reducing the risk of complications during
complex cardiac surgeries.
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Contraindications
There are no absolute contraindications for CPB; however, surgeons may postpone surgery
considering associated complications or pathophysiology in specific scenarios. These situations
include acute kidney impairment, acute cerebral stroke, chest infection, or severe asthma
exacerbations.[5][7][8][9] Delaying surgery when possible is preferred to optimize outcomes and
minimize risks.
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Equipment
The components of the CBP machine include the following:
Venous Cannulas
Venous cannulas divert deoxygenated blood from the body into the CPB circuit. They are
typically placed in the right atrium, superior vena cava, or inferior vena cava. The design of
venous cannulas ensures efficient drainage and minimizes the risk of air embolism. They come
in various sizes and shapes to accommodate different patient anatomies and surgical
requirements.
Arterial Cannulas
Arterial cannulas return oxygenated blood from the CPB circuit to the patient’s arterial system.
They are usually inserted into the ascending aorta but can also be placed in peripheral arteries
like the femoral artery. The design of arterial cannulas focuses on minimizing blood flow
resistance and reducing the risk of vessel injury or dissection. The aortic cannula must be safe to
insert smoothly (atraumatic tip and surface), with no high-pressure gradient jet at the tip that
could dislodge atheromatous plaques, and of a suitable size to allow sufficient flow. Various
designs of arterial cannulas are available. Nothing is termed the best cannula; each cannula
enjoys specific features that suit a particular situation. All cannulas are used in practice, and it is
up to the surgeon to assess the situation and decide which to use. The following briefly describes
some of the features and their values.
 Right-angled
o Prevents perforating the posterior wall of the aorta
o Can selectively perfuse an arch branch
 Straight
o Prevents selective arch vessel perfusion
o Can penetrate the posterior wall of the aorta
  Beveled tip
o Easier insertion
o Higher pressure gradient delivered at the tip
 Diffusion tip
o Less pressure gradient allows better perfusion of arch branches
o Slightly more complex
 Wire reinforced
o Allows higher flow for a smaller cannula
o More immune to iatrogenic dissection
 Flanges
o Hemostatic
o Acts as anchor points for the purse strings
Heat Exchanger
Heat exchangers in CPB circuits regulate the temperature of the blood. They allow for the
controlled cooling and warming of blood, crucial for protecting organs and tissues during
surgery. The exchanger typically consists of a series of metal plates or tubes through which
blood and a temperature-controlled fluid (usually water) flow, allowing heat transfer between the
2.
Oxygenators
 Membrane oxygenators
o These devices use a semipermeable membrane to facilitate gas exchange. Blood
flows on 1 side of the membrane, while a gas mixture flows on the other. Oxygen
diffuses into the blood, and carbon dioxide diffuses out. Membrane oxygenators
are preferred for their efficiency and lower risk of blood trauma.
 Bubble oxygenators
o In these devices, blood is oxygenated by direct contact with oxygen bubbles.
While effective, membrane oxygenators have largely replaced bubble oxygenators
due to higher risks of blood trauma, embolism, and inflammatory responses.
Reservoir Container
 Open reservoirs
o These containers collect blood from the patient and allow it to mix with air before
entering the CPB circuit. They offer easy access for adding medications or fluids
but pose a higher risk of air embolism and contamination.
  Closed reservoirs
o These containers prevent blood from coming into contact with air, reducing the
risk of air embolism and contamination. Closed systems are generally safer and
more efficient at maintaining blood volume and pressure.
Pumps
 Roller pumps
o These pumps use rollers to compress a section of tubing, propelling blood
forward. They are simple and reliable but can cause blood trauma and are
associated with risks of tubing rupture and air embolism.
 Centrifugal pumps
o These use a rotating impeller to create a centrifugal force that moves blood
through the circuit. They are gentler on blood cells, reducing hemolysis and
trauma, and provide a more consistent flow without the risk of tubing rupture.
Tubing
All tubes are made of polyvinyl chloride, which is nonallergic, nonmutagenic, nontoxic,
nonimmunogenic, pliable, flexible, and transparent. The venous tube is 1/2 inch (12 mm), the
arterial tube is 3/8 inch (8 mm), and the vents and suckers are 1/4 inch (6 mm).
Cardiotomy Suckers
Cardiotomy suckers are used to remove blood from the surgical field and return it to the CPB
circuit. They help maintain a clear operative field and reduce blood loss. Blood collected by
cardiotomy suckers is filtered to remove air and debris before being reinfused into the patient.
Vents
Vents are used to decompress the heart and prevent air embolism during CPB. They are typically
placed in the left ventricle, left atrium, or pulmonary artery. Vents ensure that air does not
accumulate in the heart chambers, which could lead to serious complications. They also help
manage heart volume and pressure during surgery.
Adjunct Equipment
This includes the level detector, arterial line pressure meter, arterial line bubble trap and filter,
cardioplegia line pressure meter, gas line filter, gas flow meter, and 1-way valves on cardiac
vents (see Image. Cardiopulmonary Bypass Figures and Tables).
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Personnel
A highly skilled, multidisciplinary team is needed to successfully implement CPB and patient
safety. The following personnel are typically involved in the process:
 Cardiac surgeon
 o Oversees the entire surgical process, including the setup and initiation of CPB
o Ensures correct cannulation for CPB
o Manages surgical interventions while the heart is on bypass
 Anesthesiologist
o Administers anesthesia and monitors the patient's vital signs
o Manages the patient's hemodynamics and fluid balance
o Coordinates with the perfusionist and surgeon to ensure optimal conditions for
CPB
 Perfusionist
o Sets up and manages the CPB circuit, including oxygenators, pumps, and
cannulas
o Monitors and adjusts blood flow, oxygenation, and other parameters
o Ensures proper anticoagulation and manages any complications related to CPB
 Surgical nurses
o Scrub nurse
 Prepares and hands surgical instruments to the surgeon
o Circulating nurse
 Manages the overall environment of the operating room, supplies
necessary equipment, and ensures sterility
 Cardiovascular technician
o Helps in the setup and testing of CPB machinery
o Assists the perfusionist with equipment management and troubleshooting
 Intensive care unit staff
o Monitors and manages the patient's recovery postsurgery
o Ensures proper functioning of life support systems and manages complications
 Pharmacist
o Prepares and provides medications required during and after the procedure
o Advises the medical team on drug interactions and optimal pharmacological
management
 Biomedical engineer
 o Ensures that all CPB equipment is functioning correctly
o Performs regular maintenance and repairs as needed
 Respiratory therapist
o Assists with ventilation settings and management before, during, and after CPB
o Monitors blood gases and adjusts ventilator settings accordingly
 Echocardiographer
o Conducts intraoperative echocardiograms to guide the surgeon
o Assists in the assessment of cardiac function before, during, and after CPB
 Clinical pathologist
o Ensures timely analysis of blood samples for coagulation, oxygenation, and other
parameters
o Advises the medical team on laboratory findings and their implications for patient
care
 Sterile processing technicians
o Sterilize and prepare surgical instruments and equipment
o Ensure timely availability of sterile supplies during the procedure
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Preparation
Preoperative Assessment
Before starting CPB, a thorough preoperative assessment is crucial to identify potential risks and
ensure patient safety. This includes:
 History and physical examination
o Evaluating the patient's cardiovascular and pulmonary status, comorbid
conditions, and previous surgical history
 Diagnostic tests
o Performing echocardiography, coronary angiography, and other relevant imaging
studies to assess the heart's anatomy and function
 Laboratory tests
o Checking complete blood count, coagulation profile, electrolytes, renal, and liver
function tests
Anesthesia Induction
  General anesthesia
o The patient is administered general anesthesia, ensuring they are fully
unconscious and immobile during the procedure.
 Monitoring
o Invasive and noninvasive monitoring devices are placed, including arterial lines,
central venous lines, pulmonary artery catheters, and transesophageal
echocardiography.
Patient Positioning
 The patient is positioned supine on the operating table, ensuring optimal access to the
surgical site and cannulation points.
 Proper padding and support are provided to prevent pressure injuries and ensure patient
comfort.
Surgical Site Preparation
 The surgical site is sterilized using appropriate antiseptic solutions.
 Sterile drapes are placed around the surgical field to maintain a sterile environment.
Heparinization
 CPB is a nonendothelial circuit. Blood that is not well anticoagulated is prone to massive
clotting. Accordingly, before going on bypass, a specific dose of intravenous heparin is
given (300 units/kg or 3 g/kg). The sufficient level of anticoagulation is judged by
checking the activated clotting time (ACT) in the operating room. The following ACT
values indicate if there is adequate heparinization:
o >300 s is safe for cannulation
o >400 s is safe for going 'on bypass' (ie, starting CPB)
o >480 s is safe for initiating deep hypothermic circulatory arrest
 If the ACT only increases marginally after full heparinization, heparin resistance may be
suspected, commonly due to antithrombin III (AT3) deficiency. After consulting the
surgeon, if a total dose of 600 units/kg of heparin does not achieve an ACT greater than
480 seconds, recombinant AT3 concentrate should be considered. Alternatively, fresh
frozen plasma, which contains AT3, may be administered. The ACT is checked every 30
minutes during the operation, and if it falls below 480 seconds, an additional 500 units of
heparin are administered.
Arterial Cannulation
Arterial cannulas are placed to return oxygenated blood from the CPB circuit to the patient. They
can be placed centrally or peripherally. The choice between central and peripheral cannulation
and the specific peripheral site depends on the patient's anatomy, the type of surgery, and the
surgeon's expertise. Each approach has advantages and limitations that must be carefully
considered to optimize patient outcomes. They are described below:
 Central cannulation
o Pros:
 Direct access to the heart
 Involves cannulating the ascending aorta and right atrium or vena
cava, providing direct access to the heart and great vessels
 Optimal flow rates
 Allows for high flow rates and efficient CPB management
 Reduced risk of limb ischemia
 Since cannulation is performed directly on the heart, peripheral
limbs are not at risk of ischemia.
 Easier management of cardiac venting
 Facilitates better control of cardiac decompression and venting
o Cons:
 Increased surgical invasiveness
 Requires a sternotomy or thoracotomy, which are more invasive
and carry higher risks of complications and longer recovery times
 Risk of aortic dissection
 Manipulating ascending aorta carries a risk of aortic dissection or
injury
 Limited in reoperations
 Can be challenging in patients with previous cardiac surgeries due
to adhesions and scar tissue
o Central cannulation is the most commonly used site in practice; however, it is less
favored in certain circumstances, such as:
 Aortic arch surgery
 In the past, surgeons cannulated the ascending aorta first to achieve
a hypothermic circulatory arrest. They removed the cannula and
reinserted it into the carotid artery to provide antegrade cerebral
perfusion. The same cannula can cannulate the axillary artery,
reducing manipulation and time.
 Aortic aneurysm surgery
  Sometimes, the aorta is dilated or aneurysmal, and there is a risk of
rupture during a sternotomy; thus, using peripheral cannulation
first on bypass before opening the chest could be a safer option.
 Aortic dissections
 The whole aorta could sometimes be obscured by the false lumen.
 Peripheral Cannulation
o Pros:
 Less invasive
 Can be performed without a sternotomy, reducing surgical trauma
and recovery time
 Suitable for minimally invasive procedures
 Ideal for minimally invasive cardiac surgeries and procedures
requiring rapid cannulation and initiation of CPB
 Alternative in operations
 Can be advantageous in patients with previous sternotomies or
complex chest anatomy
o Cons:
 Risk of limb ischemia
 Cannulation of peripheral arteries, especially the femoral artery,
can lead to limb ischemia and require additional monitoring and
management.
 Suboptimal flow rates
 Peripheral cannulation may not achieve the same flow rates as
central cannulation, potentially affecting the efficiency of CPB.
 Cannulation site complications
 There is an increased risk of local complications, such as infection,
bleeding, and vessel injury at the cannulation site.
o Peripheral cannulation sites
 Axillary artery
 Pros:
 Reduced risk of limb ischemia
  The axillary artery provides a reliable site with a
lower risk of limb ischemia compared to femoral
cannulation.
 Adequate flow rates
 Provides sufficient flow rates for CPB and is
suitable for extended periods
 Less atherosclerosis
 Less prone to atherosclerotic disease, reducing the
risk of embolic events
 Cons:
 Technical difficulty
 Can be technically challenging and requires careful
surgical dissection
 Risk of brachial plexus injury
 Proximity to the brachial plexus increases the risk
of nerve injury during cannulation
 Innominate artery
 Pros:
 Central flow rates
 Provides flow rates comparable to central
cannulation, supporting effective CPB
 Reduced risk of limb ischemia
 Avoids limb ischemia associated with femoral
artery cannulation
 Cons:
 Technical complexity
 Technically demanding and requires precise
surgical technique
 Risk of stroke
 Manipulation of the innominate artery can increase
the risk of cerebrovascular events.
 Femoral artery
 Pros:
  Ease of access
 Easily accessible, especially in emergency
situations or minimally invasive procedures
 Rapid cannulation
 Allows for quick establishment of CPB, which is
beneficial in urgent cases
 Cons:
 High risk of limb ischemia
 Necessitates continuous monitoring and potential
use of distal perfusion catheters
 Atherosclerosis
 More likely to be affected by atherosclerosis,
increasing the risk of embolic complications
 Lower flow rates
 May not achieve the same flow rates as central or
other peripheral sites, potentially affecting CPB
efficiency
Venous Cannulation
Venous cannulas, which can be 1- or 2-stage, are inserted to drain deoxygenated blood from the
patient into the CPB circuit.
 1-stage venous cannulation
o A single cannula is inserted into the right atrium, providing drainage from the
superior vena cava (SVC) and inferior vena cava (IVC).
o Advantages:
 Simplicity: easier and quicker to insert
 Less invasive: requires fewer incisions and less manipulation of the heart
and great vessels
 Reduced bleeding risk: fewer entry points minimize the risk of bleeding
complications
o Disadvantages:
 Limited flow: may not provide optimal venous drainage, particularly in
larger patients or during procedures requiring full cardiac decompression
  Inadequate for complex surgeries: not suitable for procedures requiring
complete isolation of the heart, such as certain valve repairs or congenital
heart defect corrections
o 1-stage is used in selective indirect bicaval cannulation.
o 1-stage right-angled is used in selective direct bicaval cannulation (avoids back
wall abutting and block)
 2-stage venous cannulation
o Involves 2 separate cannulas, 1 placed in the SVC and 1 in the IVC, or a 2-stage
cannula that provides separate drainage ports for the SVC and IVC
o Advantages:
 Optimal drainage: provides superior venous drainage and decompression
of the heart
 Versatility: suitable for complex cardiac procedures where complete
cardiac isolation is necessary
 Enhanced control: allows for precise management of venous return and
better visualization of the surgical field
o Disadvantages:
 Complexity: more technically demanding and time-consuming to insert
 Increased invasiveness: requires additional incisions and manipulation of
the heart and great vessels, increasing the risk of complications
o 2-stage is used in cavoatrial venous cannulation
There are 3 types of venous cannulation that can be performed:
 Cavoatrial cannulation
o Involves a cannula inserted at the junction of the IVC and the right atrium
o Advantages:
 Simpler technique: easier to perform and requires less precise placement
compared to bicaval cannulation
 Adequate drainage: provides effective drainage for many standard cardiac
procedures
o Disadvantages:
 Limited control: less control over individual vena cava drainage, which
may not be suitable for more complex surgeries requiring complete
isolation of the SVC and IVC
 Direct selective bicaval cannulation
 o Involves placing separate cannulas directly into the SVC and IVC
o Advantages:
 Complete isolation: provides complete isolation of the right atrium, which
is essential for procedures such as tricuspid valve repair and certain
congenital heart defect corrections
 Optimal drainage: ensures maximum venous return and cardiac
decompression
o Disadvantages:
 Technical complexity: more challenging and time-consuming to perform
 Increased risk: higher risk of bleeding and vessel injury due to multiple
cannulation sites
 Indirect selective bicaval cannulation
o Utilizes a 2-stage cannula that has separate drainage ports for the SVC and IVC,
inserted through a single incision
o Advantages:
 Simplified procedure: easier and quicker to perform compared to direct
bicaval cannulation
 Adequate drainage: provides effective drainage and partial isolation of the
heart
o Disadvantages:
 Less complete isolation: does not offer complete isolation of the right
atrium like direct bicaval cannulation
 Potential for incomplete drainage: may not be suitable for all complex
cardiac procedures requiring complete separation of venous return
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Technique or Treatment
After the preparation is finished and the cannulas have been placed, CPB begins. During CPB, a
heart-lung machine temporarily takes over the patient's blood circulation and oxygenation. The
process begins with inserting venous cannulas into the right side of the heart to draw blood
passively into a reservoir, using gravity based on the height difference between the patient and
the reservoir. The blood is then pumped through an oxygenator, where it is oxygenated and
transformed into blood suitable for systemic circulation. The oxygenated blood is split into 2
streams: 1 stream is returned to the patient via an aortic cannula inserted into the distal ascending
aorta, while the other stream, mixed with a cardioplegia solution, is delivered to the aortic root
via a cardioplegia pump. This separation ensures that the heart receives only the cardioplegia
solution, causing arrest, while the rest of the body receives oxygenated blood.
Cross-clamping the aorta is crucial for intracardiac repair as it induces ischemia in the heart.
Cardioplegia, a myocardial protection method, involves perfusing the heart with a solution to
cause electromechanical arrest, thereby reducing myocardial oxygen consumption. The
cardioplegia cannula is inserted proximally, while the aortic cannula is placed distal to the clamp.
Cardioplegia is delivered via a separate pump, either antegrade into the aortic root, retrograde
into the coronary sinus, or both. A transesophageal echocardiogram can guide the placement of
the balloon-tipped retrograde cannula into the coronary sinus. Retrograde cardioplegia alone is
insufficient for right ventricle protection. However, it may be necessary in addition to antegrade
or ostial cardioplegia when aortic insufficiency is present. With aortic insufficiency, antegrade
cardioplegia may leak through the incompetent valve, leading to inadequate cardiac protection
due to insufficient solution delivery and myocardial stretch of the left ventricle. In such cases,
retrograde cardioplegia may also be used. Ostial cardioplegia is administered in cases of severe
aortic regurgitation.[10]
CPB also includes mechanisms to adjust the blood's chemical composition and temperature via a
heat exchanger, ensuring the patient's metabolic needs are met. Throughout the procedure,
cardiotomy suckers collect and salvage any blood lost during surgery, minimizing the need for
transfusions. Cardiac vents maintain optimal cardiac pressures and prevent heart enlargement.
Once the surgical procedure is complete, the aortic cross-clamp is applied to isolate the heart
from the rest of the circulation, enabling the surgeon to work on a bloodless field. The CPB
machine's careful coordination of these functions ensures continuous perfusion of vital organs
and protection of myocardial tissue during the surgery, maintaining patient stability and viability
throughout the procedure.
The following is an example of how CPB is conducted in the operating room:
Going "On Bypass"
The surgeon performs arterial and venous cannulation and then connects the arterial and venous
cannulas to the pump. Connecting the arterial cannula first is beneficial for several reasons, with
one being that it allows the patient to transfuse volume into circulation if they become
hemodynamically compromised. Venous cannulation can lead to atrial irritation and
supraventricular arrhythmias, such as atrial fibrillation, which may be poorly tolerated in certain
heart conditions like left ventricular hypertrophy or aortic stenosis. An atriotomy for the venous
cannula will also lead to blood loss that could compromise the patient. With the arterial cannula
ready and connected, the surgeon can quickly correct this by instructing the perfusionist to
transfuse the volume.
Once the connections are satisfactory, the surgeon asks the anesthetist and the perfusionist if they
are ready to go on bypass. If all is well, they give the go-ahead order to go "on bypass." As both
sides of the circuit are in continuity, the surgeon must "divide the lines." Before doing so, the
surgeon must confirm 2 things with the perfusionist:
 The pump is off.
o If not, the pump will push against a closed clamp, potentially causing machine
breakage.
 The venous line is clamped.
 o If not, the fluid in the venous line will siphon back into the reservoir.
Before connecting the lines to the cannulas, the surgeon instructs the perfusionist to:
 Push some fluid in the arterial cannula to de-air the connection completely (ie, "come
around").
 Pull back some fluid in the venous cannula, reduce tube length, and ensure it sits
properly.
After the surgeon connects the arterial line tube to the aortic cannula, they confirm:
 Good swing
o Ensuring the cannula is in continuity with the bloodstream (ie, inside the aorta)
 Good pressure
o Ensuring the cannula is not in an inappropriate site (eg, back wall, dissection
lumen)
An example of a typical dialogue during this part of CPB is:
 Surgeon: ACT ok?
 Anesthetist: ACT satisfactory.
 Surgeon: Cannulating (The anesthetist could instruct the surgeon to wait if pressure is
high.)
 Anesthetist: Go ahead.
 Surgeon: Dividing the lines.
 Perfusionist: Off and clamped.
 Surgeon: Connecting arterial line (A-line), come around, please, stop; the A-line is
connected.
 Perfusionist: Good swing and pressure.
 Surgeon: Cannulating atrium, return losses, please.
 Perfusionist: Transfusing.
 Surgeon: Take back, please; connected, ready to go on bypass
 Perfusionist/anesthetist: All good.
 Surgeon: On bypass, please.
Confirming Satisfactory Bypass
Confirming satisfactory CPB involves several key steps to ensure the patient is stable and that
the bypass circuit functions correctly. By meticulously checking these parameters and
maintaining clear communication among the surgical team, perfusionist, and anesthesiologist,
satisfactory CPB can be confirmed, ensuring the safety and stability of the patient throughout the
surgical procedure. These steps include:
 Adequate venous drainage
o Ensure the venous cannula is properly positioned and draining blood into the
reservoir. This is typically confirmed by observing a steady blood flow into the
venous reservoir without signs of air or excessive resistance.
 Arterial line pressure
o Verify that the arterial line pressure is within the normal range. This indicates that
blood is adequately pumped from the oxygenator to the patient's arterial system.
Proper arterial cannula placement prevents complications like dissection or
inadequate perfusion.
 Oxygenation and blood gases
o Regularly check blood gas measurements and oxygenation levels to confirm that
the oxygenator effectively oxygenates the blood and removes carbon dioxide. The
blood gas values should be within the expected physiological range.
 Hemodynamic stability
o Monitor the patient's vital signs (including blood pressure, heart rate, and central
venous pressure) to ensure they remain stable. Hemodynamic parameters should
indicate adequate perfusion of vital organs.
 Flow rates
o Assess the pump's flow rates to ensure they match the calculated patient's size and
condition requirements. The flow rate should be sufficient to maintain systemic
perfusion without causing hemodilution or other issues.
 Temperature management
o Check the temperature of the blood returning to the patient to ensure the heat
exchanger appropriately regulates it. The temperature should be maintained
within a safe range to avoid hypo- or hyperthermia.
 Visual inspection
o Perform a visual inspection of the entire CPB circuit to ensure no leaks, air
bubbles, or malfunctions are present. Ensure all connections are secure and that
the circuit is operating smoothly.
 Communication with surgical and anesthesia teams
o Constant communication with the surgical and anesthesia teams is crucial to
ensure that all members know the CPB status and any potential issues. The
surgeon should confirm good arterial line swing and pressure, indicating proper
placement and function.
  Cardioplegia delivery
o Ensure that the cardioplegia solution is being delivered appropriately to achieve
myocardial protection. Verify that the heart is adequately arrested and protected
during the procedure.
Weaning Off Bypass
Weaning off CPB is a step-by-step reversal of the bypass process, ensuring the patient's heart and
lungs gradually resume normal functions. Here's how the weaning process typically unfolds:
Step 1: Restarting the Heart and Lungs
The first step in weaning off bypass involves resuming the heart's electrical and mechanical
activity and allowing blood to flow to the lungs. This enables both organs to function partially
while the pump is still running. The heart is restarted by rewarming, de-airing, and placing
epicardial pacing (discussed in a separate chapter). Lung reperfusion occurs simply by re-
ventilating the lungs.
 Rewarming
o Rewarming is essential to reestablish the metabolism of cardiac myocytes. Due to
the physical properties of body fluids, this process takes longer (0.3-0.5 °C/min)
than the cooling process (0.5-1.5 °C/min). Rewarming is achieved systemically
via the heat exchanger and using a "bear hugger" to warm the lower extremities.
Rewarming must not happen too quickly to avoid creating microbubbles (Boyle
law) and not overheating to prevent the denaturation of plasma proteins.
 De-airing
o De-airing is a critical step in the weaning process that aims to expel all air from
the heart and great vessels before allowing the heart to control circulation
independently. Residual air in the heart and aorta can embolize any organ and
cause severe damage. Air embolizing of the coronary or carotid arteries is of
particular concern, as these are the first branches of the aorta. The right coronary
artery is especially vulnerable to air embolism due to its higher anterior position.
If air embolizes down the right coronary artery, it can cause right ventricular
distension.
o The CPB pump manages air particles through maneuvers such as escalating pump
flow and increasing pressure to expel air down the system. In severe cases, more
drastic measures may be required, such as going back on bypass or conducting
antegrade/retrograde cerebral perfusion. Ensuring satisfactory de-airing before
dismantling the circuit is essential.
o When the heart is fully decompressed, the distance from the venous cannula to the
cross-clamp, including the right heart, pulmonary arteries, lung parenchyma,
pulmonary veins, and left heart, should be free of blood but will contain some air.
This air is exaggerated by surgical breaches (eg, CABG) since they allow ambient
air into the space. Sources of air entering this space during cardiac surgery include
surgical (atriotomy, aortotomy, cannulation site), anesthetic (central venous
 catheter line), CPB pump (exhaustion of reservoir level, unsecured stock ports,
cavitation), and natural dead space.
 Lung reperfusion
o The lungs are reventilated to resume their function, allowing blood to flow
through the lungs.
Step 2: Confirming Heart and Lung Function
The surgeon must confirm the function of the heart and lungs by examining specific parameters,
such as arterial blood gas and cardiac output. These parameters ensure that both organs function
properly before fully weaning off CPB. The following is a summary of the parameters.
 “No” x 2
o No conditions include graft failure, valve leakage, dissection, and no residual air.
 "Satisfactory" x2
o These are satisfactory pacing and ventilation.
 "Physiological" x2
o These are the physiological temperature (35-37 °C) and physiological gases
(arterial blood gases, potassium [K+], PO2).
Step 3: Gradual Weaning from the Pump
If the heart and lung functions are satisfactory, the surgeon instructs the perfusionist to slow
down the pump until it is completely off gradually. The perfusionist starts by gradually clamping
the venous line, limiting the amount of blood returning from the patient. This causes more blood
to flow into the patient than returns, effectively filling the heart. This process continues until a
satisfactory contraction is achieved, reaching the highest point of the Frank-Starling curve. At
this point, the perfusionist begins to slow down the main head pump's flow as instructed by the
surgeon. This limits the blood flowing back to the heart until the venous line is fully clamped and
the main head pump is entirely switched off. The arterial and venous lines are clamped, and the
lungs and heart functions are monitored for a few more minutes to ensure stability.
Step 4: Dismantling the Circuit
At the end of the operation, heparin is reversed by administering protamine (1 mg/100 units of
heparin given). Protamine, derived from salmon sperm, reverses heparin anticoagulation by
forming 1:1 complexes with the negatively charged heparin molecules. Protamine administration
can be associated with adverse effects such as hypotension, pulmonary vasoconstriction,
bronchoconstriction, reduced cardiac output, and anaphylaxis. The risk of hypotension is
particularly dependent on the rate of administration.
The surgeon dismantles the CPB circuit only if the heart and lung functions are confirmed to be
normal. This is done stepwise in the following order. Venous cannula out (but leave the purse
string intact), root vent out, then aortic cannula out (after giving protamine and satisfactory
filling). Throughout the procedure, the surgeon keeps an eye on the heart parameters, bearing in
mind the situation might necessitate returning to the bypass at any time; certain precautions are
taken to enable that. Fill the venous line with crystalloid to reprime it (siphon venous line). The
perfusionist checks the heparinization, occlusion, and reservoir levels. The surgeon leaves the
atrial purse strings ready to reuse if needed.
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Complications
CPB is a crucial technology in cardiac surgery but is also associated with various complications
that can affect patient outcomes. One significant complication is systemic inflammatory response
syndrome, triggered by blood contact with the nonendothelial surfaces of the CPB circuit. This
response releases inflammatory mediators, causing fever, leukocytosis, and capillary leak
syndrome. Pharmacological strategies with antioxidant properties show promising potential in
mitigating these issues, particularly in reducing complications, such as vasoplegic syndrome
during CPB.[6]
Another critical issue is coagulopathy, often characterized by platelet dysfunction and
consumption of clotting factors that can lead to bleeding complications. Additionally, CPB is
associated with neurological complications such as stroke, which can result from emboli,
hypoperfusion, or inflammatory responses affecting cerebral blood flow. Other complications
include acute kidney injury due to altered renal perfusion, electrolyte imbalances, and the
potential for transfusion-related complications like hemolysis or infection. Vigilant management
and advanced techniques aim to mitigate these risks and improve patient outcomes in cardiac
surgery.
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Clinical Significance
CPB holds profound clinical significance in modern cardiac surgery, enabling intricate
procedures that are otherwise impossible. CPB allows surgeons to perform precise repairs and
interventions with minimal intraoperative bleeding by creating a bloodless and motionless
environment for the heart. This technology ensures continuous oxygenation and circulation of
blood throughout the body, sustaining vital organ function during surgery. CPB plays a crucial
role in treating complex cardiac conditions such as congenital heart defects, coronary artery
disease, and valvular heart disease, thereby improving patient outcomes and extending lives.
However, it also presents challenges, including potential complications—many of which can be
life-threatening. Because of the risks, CPB requires vigilant monitoring and management for
optimal patient safety and recovery. To reduce the risk of complications from CPB, many
surgeons also perform off-pump heart surgery.[11][12][13][14]
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Enhancing Healthcare Team Outcomes

Effective CBP management involves a multifaceted strategy that includes advanced skills,
strategic planning, interprofessional communication, and seamless care coordination. Physicians
and surgeons must be adept at CPB techniques and equipment, making real-time decisions and
managing complications. Advanced practitioners and nurses are essential for preoperative patient
assessments, intraoperative monitoring, and postoperative care. They ensure patient stability and
support the surgical team with their expertise in pharmacologic management and CPB
machinery. Pharmacists optimize medication management, particularly the dosing of
anticoagulants and reversal agents, and monitor for adverse reactions. Perfusionists, crucial for
operating the heart-lung machine, must meticulously manage the blood flow and oxygenation.
Clear and effective communication among these professionals ensures that critical information,
such as patient status and procedural steps, is shared promptly to enhance patient safety and
outcomes.
Care coordination is essential for the success of CPB and involves preoperative planning,
intraoperative management, and postoperative care. Preoperatively, thorough patient assessments
and team discussions help identify potential risks and develop individualized care plans. During
surgery, constant communication ensures every team member knows the procedure's progress
and any necessary adjustments. Postoperatively, coordinated care involves monitoring and
managing patient recovery, swiftly addressing complications, and rehabilitation planning. This
collaborative approach improves team performance and enhances patient-centered care by
ensuring that each patient receives the most appropriate and effective treatment, optimizing
outcomes, and ensuring patient safety.