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Eur J Cardiothorac Surg 2007;31:1070-1075. doi:10.1016/j.ejcts.2007.01.065
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Clinical advantages of using mini-bypass systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo clinical perspective

Mathias Perthel*, Lémir El-Ayoubi, Andreas Bendisch, Joachim Laas, Markus Gerigk

Cardiovascular Center Bad Bevensen, Clinic for Cardiac and Thoracic Surgery, Bad Bevensen, Germany

Received 21 September 2006; received in revised form 18 January 2007; accepted 31 January 2007.

* Corresponding author. Address: Klinik für Herz-Thorax-Chirurgie, Herz- und Gefäßzentrum Bad Bevensen, Roemstedter Str. 25, 29549 Bad Bevensen, Germany. Tel.: +49 5821 82 1702; fax: +49 5821 82 1777. (Email: m.perthel{at}hgz-bb.de).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Statistics
 4. Results
 5. Discussion
 6. Conclusion
 Appendix A
 References
 
Objective: In an effort to minimize the effect of extracorporeal circulation (ECC), mini-bypass is gaining clinical acceptance in routine coronary artery bypass grafting (CABG). These small circuits target combine the clinical advantages of reduced prime, 100% bio-coating and suction blood separation. We demonstrate that the use of mini-bypass in routine CABG reduces homologous blood product use and postoperative bleeding. Our goal was to also demonstrate that these small systems are effective in gaseous microemboli (GME) management as compared to a conventional extracorporeal system. Methods: Prospective, randomized study comparing 30 mini-bypass (Dideco ECC.OTM) to 30 conventional systems (n = 30, Dideco 903 AvantTM). Study included CABG cases only, independent of preoperative coagulative status; clinic ethical committee approval and informed patient consent was obtained before initiating study. Results: There were no statistical differences in terms of patient demographics. Statistically significant differences were seen in transfusion frequency (27% of the study group vs 43% in the control group, p = 0.05), transfused volume (133.3 ± 244.5 ml vs 325 ± 483.1 ml, p < 0.05), fresh frozen plasma (0 unit vs 3 units, p < 0.001), postoperative bleeding (301.8 ± 531.9 ml vs 785.5 ± 1000.4 ml, p < 0.05) and GME activity post-arterial filter (0.14 µl vs 5.32 µl, p < 0.05). Conclusions: The adoption of mini-bypass significantly potentially reduces hemodilution, donor blood usage, postoperative bleeding and exposure to GME in routine CABG patients as compared to the use of conventional extracorporeal circulation circuits.

Key Words: Cardiopulmonary bypass • Low prime • Venous air • Air removal


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Statistics
 4. Results
 5. Discussion
 6. Conclusion
 Appendix A
 References
 
Over the past few years there has been a renewed interest in challenging some of the commonly accepted philosophical cornerstones of extracorporeal circulation (ECC). Hemodilution was recognized as an effective way to deal with the size of the system used for ECC and to manage the patient in hypothermia [1]. The recent emergence of a significantly older, more complex patient population has renewed interest in improvement of the cardiopulmonary bypass (CPB) circuit in terms of hemodilution reduction. Excessive hemodilution has been linked to being the primary cause of impairment of homeostasis in terms of drop in coagulation and fibrinolytic proteins during CPB [2] and it has been identified as a principal contributor to organ dysfunction during CPB [3] and increased risk of long term morbidity and short term mortality [4,5]. Reduced use of homologous blood products logically follows from a reduction in hemodilution during ECC, consequently there is also growing interest in the field of cardiovascular surgery regarding the reduction of blood product use via significant reduction in hemodilution. The use of homologous blood products has been linked to increased frequency of organ dysfunction/failure, neurological dysfunction and long-term morbidity/mortality risk [6,7] in addition to the risk of transfusion related communicable diseases. There are therefore obvious advantages associated with a reduction in blood product use in ECC.

The concept of mini-bypass combines the known clinical advantages of suction blood separation, biocompatible coating, and significantly reduced prime in order to better maintain patient homeostasis, preserve autologous blood and effect meaningful improvements in postoperative morbidity in on-pump cardiac surgery [8]. The mini-bypass system includes an integrated venous bubble trap, centrifugal pump, heat exchanger, and oxygenator and is designed for use with an autotransfusion/cell saving system for sequestration of aspiration blood.

However, the capacity of these low prime systems to manage gaseous microemboli (GME) activity has recently been called into question. Studies have confirmed that GME management in mini-bypass circuits might not be as effective as conventional systems for particular configurations of the mini circuit [9,10]. GME in conventional ECC is well reported in the literature and the impairment of neuro-cognitive function appears to be a common finding after on-pump open-heart surgery and an important part of morbidity and mortality [11,12]. There are numerous published reports that describe a correlation between number of microemboli and postoperative neuro-cognitive dysfunction [13]. Microembolic signals (MES) detected by transcranial Doppler (TCD) have been described in virtually all patients undergoing revascularization in conventional ECC [14,15]. A smaller portion of these signals might be directly associated with surgical, anesthesiologist or perfusionist action during the operative course [16,17], but the larger portion might be generated from the circuit and cannot completely eliminated using passive filtration systems like an open hardshell venous reservoir and arterial filter.

Understanding the importance in managing venous air and GME in the ECC circuit, some newer low prime systems with active bubble removal capability have been developed and introduced into routine clinical use. These active bubble removal systems include GME sensing systems that remove air from the venous line through the venous bubble trap automatically. The intention of this study is to evaluate one of these new mini-bypass systems with an active air management system in routine revascularization cases while investigating the hypothesis that a significant reduction in prime via use of a mini system will lead to a statistically significant reduction in homologous blood product use.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Statistics
 4. Results
 5. Discussion
 6. Conclusion
 Appendix A
 References
 
This was a prospective, randomized study from a group of 60 consecutive coronary artery bypass graft (CABG) patients comparing blood product usage, postoperative bleeding and GME activity in 30 mini-bypass systems (n = 30) to 30 conventional systems (n = 30) from January 2005 to September 2005. All procedures performed by the same surgeon and perfusionist. Apart from accepting only revascularization cases requiring extracorporeal circulation, there were no exclusion criteria and all types of patients regardless of preoperative coagulative status were admitted into the study. Approval was received from the ethical committee of Lower Saxony, with patients being required to sign informed patient consent forms in order to be included in the study. Patients were randomized by selecting a number from a pool of 60 numbers preassigned to either the mini-bypass or conventional-bypass groups. The number was selected and cross-matched to the group list by the perfusion team prior to set up of the corresponding circuit in an effort to blind the surgical team and avoid any knowledge of what system was to be used. All measurement of GME in the perfusion circuit and MES in the middle cerebral arteries of the patients was performed in vivo.

2.1 Cardiopulmonary bypass
The phosphorylcholine coated mini circuit (ECC.OTM, Dideco SrL, Mirandola, Italy), consisted of an integrated venous bubble trap, centrifugal pump and oxygenator, and an arterial filter (D733, Dideco). Circuit priming volume was 700 cc including 500 cc saline (0.9%) + 200 cc 5% glucose. A four pump position Heart Lung Machine (HLM) (Stöckert S3, Sorin Group) was used to manage the mini-bypass circuit.

Arterial cannula with straight tip (6.5 mm, Stöckert, Sorin Group) and fixation ring was used on the arterial side, while on the venous side a 30/32 venous two-stage cannula (Stöckert) and additional ligature on the side of venous cannulation was done in order to avoid air entrainment from the cannulation site. The 9 Fr 1/4 in. vent catheter (Stöckert) in the aortic root was an antegrade cardioplegia cannula with a distal vent line. The suction created by the centrifugal pump was utilized for intermittent aortic root venting, with the vent line being connected directly to the venous line. Aspirated blood was managed using a cell saver (Electa, Dideco).

The same HLM and autotransfusion system was used in the control group. A phosphorylcholine traditional open circuit was used (Dideco EvolutionTM, Sorin Group), consisting of a hardshell venous reservoir, oxygenator, and arterial filter (D713, Dideco). Priming consisted of 5000 IE heparin with 1000 cc saline (0.9%) and 800 cc glucose 5%. A minimum blood operating level in the venous reservoir of 300 ml was strictly respected.

After median sternotomy and vein harvesting of the substitutes 300 IU/kg BW heparin was administered. Myocardial protection in both groups was achieved using warm blood and a potassium loaded syringe pump, given in the aortic root with an initial dose, then repeated every 15 min. Retrograde autologous blood priming was used in both systems. The aorta was cross-clamped and the coronary anastomoses are performed on an arrested heart with a dry, still operative field. After cross-clamping the central anastomoses were sutured with partial clamping of the ascending aorta. Mild hypothermia (34 °C) was used with a target flow rate index of 2.4 l/min m2 BSA using non-pulsatile flow and alpha-stat control of acid-base management. Activated clotting time (ACT) was measured using the Medtronic ACTII system (Medtronic Inc., St Paul, Minnesota, USA) with target values for ACT ≥ 480.

2.2 Detection of MES
For the detection of MES, the middle cerebral artery was monitored bilaterally through the temporal bone window using 2 MHz probes (Nicolet 2 MHz probe, Nicolet, Estenfeld, Germany). The probes were fixed in a head frame and connected with a Doppler sonography device (Pioneer TC 4040 Medilab, Würzburg, Germany) allowing online recording by applying the FS1-algorithm. All audio and video signals were recorded on hard disc. The recording of the signals was followed by the guidelines of GME detection established in 1998 [18]. Only unidirectional signals within the Doppler velocity spectrum with an intensity of 3 dB HTL higher than the background flow signal, lasting less than 300 ms were counted as MES. Data audit was done by a subsequent off-line analysis of data using by a secondary investigator. The inner-observer variability was less than 10% of the number of signals.

2.3 Detection of GME
A two channel Doppler sonography device was used as a bubble counter (GaMPT Zappendorf, Germany), allowing online recording [19]. The investigator was also able to record on a hard disc for off-line evaluation. Both channels had a time course, in which actions by the anesthesiologist or surgeon like drug injection, lifting of the heart, etc. could be identified during the procedure for later reference. The device was mounted on the HLM and managed by the perfusionist for continuous in vivo measurement. A unique feature of this new bubble counting device is the automatic set-up of sensitivity to measurement conditions (ultrasound attenuation of the tube, coupling condition of the probe). GME ranging from 10 µm to 120 µm were counted by the device; particles (blood elements, micro-thrombi) do not influence the results. The total GME volume is calculated automatically. The device was calibrated in vitro using the manufacturer's calibration procedure. The measurement points in each circuit are provided in the Table 1 . GME was measured at the outlet of the hardshell venous reservoir and at the outlet of the arterial filter, while in the mini-bypass system the measurement points were at the inlet of the venous bubble trap and the outlet of the arterial filter.


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  		Table 1 Measurement points for GME and MES in mini-bypass and conventional ECC
 

   3. Statistics
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistics
4. Results
 5. Discussion
 6. Conclusion
 Appendix A
 References
 
All data was stored using a database created with Microsoft Access. All results were expressed as mean values ± standard deviation. Statistical analysis was performed using SPSS statistical package for Windows (version 9.0, SPSS Inc., Chicago, IL, USA). Numeric variables with normal distribution were analyzed by means of analysis of variance (ANOVA) and post hoc comparisons with Tukey honestly significant difference adjustment. {chi} 2-test was used for analysis of categorical variables. A value of less than 0.05 was considered statistically significant. Independent statistical analysis was performed by the Department of Medical Statistics, University of Hannover, Germany and by the Department of Clinical Research at the Free University Hospital, Amsterdam, Netherlands.


   4. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistics
 4. Results
5. Discussion
 6. Conclusion
 Appendix A
 References
 
The patient demographics were not statistically significant as shown in Table 2 . Anticoagulation status for the two groups was comparable as there were no differences in preoperative ASA or IV heparin use and no patients were on low molecular weight heparin. There where no statistically significant differences in pCO2 levels, pO2 levels, base excess and HCO3 intraoperatively or postoperatively as shown in Table 3 . There was a non-significant trend towards a higher number of anastamoses in the mini CPB (4.5) versus the conventional system (4.1). Intraoperative hemoglobin levels showed a significant difference on pump as can be seen in Table 3.


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  		Table 2 Preoperative patient data
 

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  		Table 3 Perfusion and blood parameters, intra and postoperative
 
The blood product study results can be seen in Table 4 . Blood product use including fresh frozen plasma (FFP) and homologous blood transfusions was tracked through the operating theater and into the Intensive Care Unit (ICU). Blood transfusions or FFP were given either in the OR or the ICU if hematocrit dropped below 26% or if platelet count dropped below 26%. In the mini-bypass group, no homologous blood transfusions were given in the OR, 27% of the patients received at least one unit of homolgous blood. In the control group 43% of the patients received at least one unit of blood in the OR or in the ICU, and there was a stastistically-significant 38% reduction in homologous blood product use (p = 0.05). For the patients that received homologous blood there was also a significant reduction in trasfused volume (0.53 ± 0.90 units blood mini-bypass vs 1.3 ± 1.93 units conventional, p < 0.05). In terms of FFP, there was also a statistically significant difference between the two groups (0 units transfused in mini-bypass group vs three patients receiving one unit FFP in the control group, p < 0.001). Cumulative postoperative bleeding during the ICU stay demonstrated a significant reduction (365.2 ± 495.7 ml mini-bypass vs 825.5 ± 975.87 ml conventional, p < 0.05), presented in Table 4. The results in terms of GME and MES are summarized in Table 5 .


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  		Table 4 Blood product usage and 24 h postoperative blood loss
 

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  		Table 5 MES and bubble volume data comparison
 
Though there was a clear trend of less MES in mini-bypass, this trend was not statistically significant. In terms of calculated GME volume, there was no statistical difference in GME from the outlet of the venous reservoir as compared to GME activity on the venous line of the mini-bypass circuit. There was a clear statistical difference in mini-bypass in terms of GME volume post-arterial filter in the mini-bypass system as compared to the conventional system.


   5. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistics
 4. Results
 5. Discussion
6. Conclusion
 Appendix A
 References
 
The use of biocompatible coatings in ECC circuits has independently been demonstrated to significantly reduce the dynamic reaction between proteins and the coated surfaces of the bypass circuit, manifesting itself as a significant reduction in platelet activation and subsequent potential for reduced postoperative bleeding [20,21]. Further studies that combined the use of the phosphorylcholine coating with shed blood separation have been able to demonstrate further clinical advantages in terms of better maintenance of patient hemostasis and preserved physiological coagulation levels to the point of achieving patient outcomes typically associated with off pump CABG [22]. The concept of mini-bypass brings a third crucial element into the combination of the biocompatible circuit and adoption of suction blood separation via prime reduction. Previous studies have demonstrated the clinical efficacy of such systems, particularly in terms of preservation of hemostasis and reduction in systemic inflammatory response [23,24]. We hypothesized that another logical advantage of reduced hemodilution should be a reduction in homologous blood products.

The clinical adoption of mini-bypass appears to have resulted in an early, clear trend towards reduced blood product use in CABG patients. A statistical significance in frequency of transfusions and amount of transfused volume was seen as well as reduced postoperative bleeding that was consistent with other published studies [21]. The elimination of the blood air interface combined with the significant reduction in blood contact surface area (approximately 1.4 m2 in mini-bypass as compared to nearly 6.0 m2 in a conventional open system) may have reduced platelet activation, but a more specific study is warranted to better understand the relationship between postoperative bleeding, improved biocompatibility via use of bio-coatings and reduction in blood contact surface area.

Despite the small surface area of 1.1 m2, the ECC.O oxygenator was able to adequately perfuse the patient as well as a conventional system with 1.7 m2 of fiber surface area. There was no clinically significant difference in terms of normal on pump oxygenation parameters and key postoperative parameters indicative of postoperative oxygenation insufficiency. Patients up to 125 kg have been easily managed by our clinic using the system, and the use of bicarbonate to manage acidosis post operatively has never been required. The higher blood hematocrit in mini-bypass on pump permits the advantage of reducing significantly the amount of oxygenation fiber required for adequate perfusion.

The average number of anastomoses was similar in mini-bypass as compared to the traditional system and demonstrates that the mini-bypass approach is as efficacious as a traditional system from the surgeon's perspective. After over 400 cases using mini-bypass in CABG it has become as routine as a traditional system for our surgical team.

The concept of mini-bypass reduces circuit prime by eliminating the hardshell reservoir, but this also means that the passive air removal capacity provided by the hardshell reservoir is eliminated. An active air removal system that senses and automatically removes venous GME must therefore be provided in a mini-bypass system. The ECC.O system includes an active air removal device called the Stöckert Air Purge Control (APC) system (Sorin Group). The air purge system uses a bubble sensor and roller pump to remove GME (approximately 100–150 µs or greater depending on the flow rate) from the venous line automatically, purging it to a de-airing storage reservoir in the circuit. The blood can be easily reintroduced back into circulation from this de-airing bag. A second bubble sensor with an electric clamp (ERC) system (Sorin Group) can be used with the APC air management system in order to stop ECC if air comes out of the bubble trap, providing a second level of GME management safety.

There was a lower level of MES in mini-bypass as compared to conventional bypass, and though this trend did not achieve statistical significance, there was a measurable difference in GME activity between the two systems that did achieve statistical significance. Less arterial GME volume is seen in the mini-bypass system as compared to a conventional system, confirming the importance of having an active air management system on the venous side in any mini-bypass circuit. It should be noted that the same trend of GME at the outlet of the reservoir has been seen by our institution regardless of the type of open venous reservoir used [25].

Special care must be taken in managing any active drainage perfusion system. Air entrainment at the venous side is effectively avoided with an additional ligature of the venous cannula, and with careful attention by the perfusionist and anesthesiologist during blood sampling and injection. The system showed a significant reduction in arterial GME even with intermittent arterial root venting into the venous line. Entrained GME is often seen in vent blood, but combining the active air removal system with aggressive management of the vent line by the perfusionist allows it to be managed efficaciously.

This was a randomized study with very limited exclusion parameters. The decision was made to widen the base for study to include consecutive CABG patients regardless of anticoagulation status in order to understand how use of mini-bypass in routine cases could impact the patient population at this institution. Only a study on a much more significant scale in terms of population size can provide an adequate numbers in order to draw conclusions regarding long term patient mortality and morbidity on a statistically significant order. Though GME activity using a mini-bypass system with an active air management system presents a clear advantage as compared to a conventional system, to demonstrate a correlation between reduction of microembolisation and improved neuropsychological outcome a large prospective randomized trial is required to elucidate the multifactorial and complex genesis of neuropsychological complications following CPB. Further studies are warranted to confirm the validity of the study.


   6. Conclusion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistics
 4. Results
 5. Discussion
 6. Conclusion
Appendix A
 References
 
The use of mini-bypass reduces on-pump hemodilution and thus donor blood usage in routine CABG patients as compared to conventional ECC circuits, and can reduce postoperative bleeding as compared to a traditional system. The mini-bypass system is safe in routine clinical use and can easily manage the same number of anastomoses that can be managed using a traditional system, and should be considered a safe and efficacious alternative to use of a traditional system in all revascularization cases. GME can be adequately managed such that it is equivalent/better than a conventional open circuit. Further studies are necessary to provide more understanding regarding the repeatability and long-term benefits of these results, and such clinical studies can only help benefit the further development of the mini ECC technology currently commercially available.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistics
 4. Results
 5. Discussion
 6. Conclusion
 Appendix A
References
 
Conference discussion

Dr S. Hagl (Heidelberg, Germany): I would like to ask you, did you also try to measure some inflammatory response in that study?

Dr Perthel: No, in this study we haven’t measured any inflammatory response. It was only a clinical study which was focused on the microbubbles, the microembolic signals and blood and transfusion. There were some other groups, for instance, Professor Liebold in Rostock, who has done a lot of work with another mini-bypass system, and he is very experienced with inflammatory response markers. This was not our project point.

Dr Hagl: Concerning the priming of the two systems, are they different?

Dr Perthel: No. It was the same, only saline, and the normal heparin dosages in both groups, there was no reduced regimen in the mini-bypass group, 300 U kg in each patient.

Dr Hagl: And the last question, how do you deal with suction?

Dr Perthel: There is no cardiotomy suction, and everything goes to the cell saver and we wash it after the procedure. And now we are so, let me say, experienced that in most of the cases, in two-thirds of the cases, it is not necessary to use the cell saver to wash this blood because you have an amount of 300 or 400 cc, and so it is not helpful to start the cell saver after the procedure. But it took a lot of time to come to this point.


   Footnotes
 
\#9734; Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistics
 4. Results
 5. Discussion
 6. Conclusion
 Appendix A
 References
 

  1. Panico FG, Neptune WB. A mechanism to eliminate the donor blood prime from the pump oxygenator. Surg Forum 1959;10:605-609.
  2. Chandler W. Effects of hemodilution, blood loss, and consumption on hemostatic factor levels during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2005;19(4):459-467.[CrossRef][Medline]
  3. Swaminathan M, Phillips-Bute B, Conlon P, Smith P, Newman M, Stafford-Smith M. The association of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg 2003;76:784-791.[Abstract/Free Full Text]
  4. Habib R, Zacharias A, Schwann T, Riordan C, Duram S, Shah A. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should the current practice be changed?. J Thorac Cardiovasc Surg 2003;125:1438-1450.[Abstract/Free Full Text]
  5. Groom R. High or low hematocrits during cardiopulmonary bypass for patients undergoing coronary artery bypass graft surgery? An evidence-based approach to the question. Perfusion 2001;16:339-343.[Free Full Text]
  6. Engoren M, Habib R, Zacharias A, Schwann T, Rioran C, Durham S. Effect of blood transfusion on long term survival after cardiac operation. Ann Thorac Surg 2002;74:1180-1186.[Abstract/Free Full Text]
  7. Zindrou D. Preoperative haemoglobin concentration and mortality rate after coronary artery bypass surgery. Lancet 2002;359:1747-1748.[CrossRef][Medline]
  8. Van Driel M. Optimized perfusion: The next logical step in the evolution of extracorporeal circulation. Canadian Perfusion Canadienne 15(1):21–5.
  9. Norman M, Sistino J, Acsell J. The effectiveness of low-prime cardiopulmonary bypass circuits at removing gaseous emboli. JECT 2004;36:336-342.
  10. Nollert G, Schwabenland I, Maktav D, Kur F, Christ F, Fraunberger P, Reichart B, Vicol C. Miniaturized cardiopulmonary bypass in coronary artery bypass surgery: marginal impact on inflammation and coagulation but loss of safety margins. Ann Thorac Surg 2005;80:2326-2332.[Abstract/Free Full Text]
  11. Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, Aggarwal A, Marschall K, Graham SH, Ley C, Ozanne G, Mangano DT, Herskowitz A, Katseva V, Sears R. Adverse cerebral outcome after coronary bypass surgery. N Engl J Med 1996;335:1857-1863.[Abstract/Free Full Text]
  12. Walzer T, Herrmann M, Wallesch CW. Neuropsychological disorders after coronary bypass surgery. J Neurol Neurosurg Psychiatry 1997;6:644-648.
  13. Pugsley WL. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 1994;25:1393-1399.[Abstract]
  14. Braekken SK, Reinvang I, Russell D, Brucher R, Svennevig JL. Association between intraoperative cerebral microembolic signals and postoperative neuropsychological deficit: comparison between patients with cardiac valve replacement and patients with coronary artery bypass grafting. J Neurol Neurosurg Psychiatry 1998;65:573-576.[Abstract/Free Full Text]
  15. Padayachee TS, Parsons S, Theobold R, Gosling RG, Deverall PB. The effect of arterial filtration on deduction of gaseous emboli in the middle cerebral artery during cardiopulmonary bypass. Ann Thorac Surg 1988;45:647-649.[Abstract]
  16. Rodriguez R, Williams K, Babaev A, Rubens F, Nathan H. Effect of perfusionist technique on cerebral embolization during cardiopulmonary bypass. Perfusion 2005;20(1):3-10.[Abstract/Free Full Text]
  17. Borger MA, Feindel CM. Cerebral emboli during cardiopulmonary bypass: effect of perfusionist interventions and aortic cannulas. J Extracorp Technol 2002;1:29-33.
  18. Ringelstein EBL. Consensus on microembolic detection by TCD. Stroke 1998;29:725-729.[Abstract/Free Full Text]
  19. Jenderka KV. Detection and estimation of microbubble size distribution in blood. In: Proceedings 16th International Congress on Acoustics, vol. 3, 1998, p. 1845–6 (ISBN 1-56396-817-7).
  20. De Somer F, van Belleghem Y, Caes F, Francois K, Arnout J, Bossuyt X, Taeymans Y, van Nooten G. Phosphorylcholine coating offers natural platelet preservation during cardiopulmonary bypass. Perfusion 2002;17:39-44.[Abstract/Free Full Text]
  21. De Somer F, van Belleghem Y, Caes F, Francois K, van Overbeke H, Arnout J, Taeymans Y, van Nooten G. Tissue factor as the main activator of the coagulation system during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2002;123:951-958.[Abstract/Free Full Text]
  22. Albes J, Stohr I, Kaluza M, Siegemund A, Schmidt D, Vollandt R, Wahlers T. Physiological coagulation can be maintained in extracorporeal circulation by means of shed blood separation and coating. J Thorac Cardiovasc Surg 2003;126:1504-1512.[Abstract/Free Full Text]
  23. Wippermann J, Albes J, Hartrumpf M, Kaluka M, Vollandt R, Bruhin R, Wahlers T. Comparison of minimally invasive closed circuit extracorporeal circulation with conventional cardiopulmonary bypass and with off pump technique in CABG patients: selected parameters of coagulation and inflammatory system. Eur J Cardiothorac Surg 2005;28:127-132.[Abstract/Free Full Text]
  24. Fromes Y, Gaillard D, Ponzio O, Cauffert M, Gerhardt M, Deleuze P, Bical O. Reduction of the inflammatory response following coronary bypass grafting with total minimal extracorporeal circulation. Eur J Cardiothorac Surg 2002;22:527-533.[Abstract/Free Full Text]
  25. Perthel M, Kseibi S, Sagebiel F, Alken A, Laas J. Comparison of conventional extracorporeal circulation and minimal extracorporeal circulation with respect to microbubbles and microembolic signals. Perfusion 2005;20(6):329-333.[Abstract/Free Full Text]



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Perfusion, November 1, 2008; 23(6): 361 - 367.
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M. Perthel, L. El-Ayoubi, A. Bendisch, J. Laas, and M. Gerigk
Corrigendum to "Clinical advantages of using mini-bypass systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo clinical perspective" [Eur. J. Cardiothorac. Surg. 31 (2007) 1070 1075]
Eur. J. Cardiothorac. Surg., December 1, 2007; 32(6): 952 - 952.
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