Modular minimally invasive extracorporeal circulation ensures perfusion safety and technical feasibility in cardiac surgery; a systematic review of the literature

Abstract

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.

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery

“…Available evidence suggests that almost 95% of cardiac surgery could be performed with a type III MiECC, while conversion to an open CPB circuit is reserved in less than 5% of cases and for a partial procedural time. 8 It should be noted that shed blood management represents an integral component of MiECC. 2 As MiECTiS emphasized in 2016 position paper, no advancement in perfusion technology could substitute for meticulous surgical technique, which remains the cornerstone for achieving an optimal surgical outcome.…”

“…85 A systematic review of the literature revealed no clinical adverse event in any patient related to MiECC to date. 8 In the light of this evidence, MiECTiS asserts that use of the modular configuration creates a safety "net" in case of any unexpected scenario and provides 100% technical feasibility and perfusion safety. Thus, modularity is the ideal technique for use as the "standard" perfusion policy by non-experienced centres, since it applies to every cardiac procedure while reducing the learning curve required for obtaining optimal results with MiECC.…”

“…These concerns were raised in anecdotal reports mainly involving type I and II MiECC circuitry. 8 The largest reported single-centre series of patients undergoing full-spectrum cardiac surgery with modular MiECC systems was published in 2021 and evaluated perfusion events and technical feasibility. 8 In a series of 403 consecutive patients, of whom a significant proportion (28%) underwent complex and emergency cardiac surgery, the technical success rate observed was 100%.…”

“…8 The largest reported single-centre series of patients undergoing full-spectrum cardiac surgery with modular MiECC systems was published in 2021 and evaluated perfusion events and technical feasibility. 8 In a series of 403 consecutive patients, of whom a significant proportion (28%) underwent complex and emergency cardiac surgery, the technical success rate observed was 100%. Conversion to an open circuit was required in 4.5% of the total cohort, excluding procedures performed under circulatory arrest.…”

Minimized Extracorporeal Circulation Is Associated with Reduced Plasma Levels of Free-Circulating Mitochondrial DNA Compared to Conventional Cardiopulmonary Bypass: A Secondary Analysis of an Exploratory, Prospective, Interventional Study

“…Still, the majority of cardiac surgery has to be performed with the use of a cardiopulmonary bypass (CPB) in order to guarantee sufficient perfusion, oxygenation, and decarboxylation of the body. Several technical upgrades have been introduced to improve the safety and efficiency of conventional CPB (cCPB) systems [ 1 , 2 ]. Nevertheless, the introduction of the minimized extracorporeal circulation (MiECC) has gained widespread interest due to its protective effect on myocardial, renal, and neurological functions [ 3 , 4 , 5 ].…”