Milena peeks shyly around her mother as the doctors pore over her medical history and test results. She is only three years old, but Milena is living on borrowed time. The tiny girl was born with two holes in her heart: each day, her heart and circulatory system have to work a little harder to overcome the deficiency. She needs a gift few can give her- the gift of life.

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A Heart Lung Bypass Machine

Perfusion as related to cardiac surgery can be defined as the movement of oxygenated blood through blood vessels to vital organs of the body.  Under normal circumstances the heart is the pump which propels the blood to the lungs, where oxygen and CO2 are exchanged.  Blood enriched of oxygen and depleted of CO2 is then pumped to the body’s organs in order to keep them functioning properly.  In cases where the heart has a defect and cannot perform the function of pumping blood, cardiac surgery must be performed to correct the congenital defect.  In order to perform this type of surgery the heart must be stopped so that the cardiovascular surgeon can open the heart and repair the defect.  Therefore the perfusionist is responsible for providing mechanical perfusion for the patient while the heart is stopped.  Utilizing a complex piece of equipment, the heart and lung machine (HLM), the perfusionist can pump oxygenated blood to the patient’s organs temporarily taking place of both the heart and lungs.  This is called placing a patient on cardiopulmonary bypass (CPB).

In order to establish CPB the surgeon places cannulas or tubes into the heart which can be connected to the HLM.  After connection to the HLM the perfusionist essentially drains the blood before it enters the heart into a sterile reservoir where it is pumped through a “manufactured lung” called oxygenator to enrich the blood with oxygen.  The oxygenated blood is then returned to the patient at predetermined calculated flow rates that are comparable to the patient’s normal circulation.  This mechanical perfusion allows the surgeon to operate on the heart since all blood is diverted from the heart to the HLM.

During the majority of heart operations, the heart is not beating and it is not receiving blood and nutrition.  To accomplish this, the surgeon injects a cold medicated solution directly into the aorta or into the coronary arteries until the heart temporarily stops.  The temporary electrical and mechanical inactivity, together with cold temperatures, hypothermia, reduces the metabolism of the heart, protecting it during the time when it does not receive blood and oxygen.

Certain defects require the perfusionist to mechanically control temperature as well.  On all routine cases the blood is warmed to normal human temperature and is held there.

Since children are so small and the operating room is cold combined with their open chest, heat loss occurs.   However, perfusionist can counteract this using warming systems connected to the HLM.  In more complex cases where the surgery may be long and involved perfusionist will cool the patient to lower temperatures to protect the organs against injury.  This can be as extreme as where the child is cooled to the point where the HLM can be turned off for a period of time to allow the surgeon to remove the tubing so that he can see the smallest of structures found in the patient’s heart to repair.  Some may have heard stories about how children who fall into icy water in winter time can be resuscitated hours later.  Perfusionist use this same mechanism with cooling since it protects vital organs and limits the necessity for oxygenated blood to some degree.

Perfusionist must make split second decisions and must constantly maintain vigilance while the patient is on CPB since the perfusionist who is operating the HLM is maintaining the patient’s life mechanically while the surgeon operates.  The perfusionist performs many tests throughout the procedure to ensure that the organs are receiving the correct amounts of oxygen and nutrients carried in the blood.  The perfusionist also monitors blood clotting which can be detrimental to the patient if certain parameters are not met.  Heparin is used to “thin” the blood so that it flows easily through the HLM and does not clot.  This test is performed many times throughout the procedure as it is critical to successful surgery on bypass.

After the surgeon repairs the defect the patient if cold, is re-warmed to normal temperature and then the heart begins to beat once the infusion of the heart stopping solution is terminated.  As the heart “wakes” up the perfusionist corrects problems with

the blood oxygenation or nutrients and prepares to terminate bypass.  To terminate bypass the perfusionist slowly restricts the amount of blood returning to the reservoir and allows the heart to become full and begins pumping the blood to the body.  As more blood is returned to the heart to pump, the perfusionist decreases the flow of the HLM until the heart is completely pumping and oxygenating blood on its own.  At this point CPB is terminated and the cannula can be removed from the heart and thinning of the blood can be reversed using another medication called protamine.  The duration of CPB is based on the type of defect being repaired and complexity of the anatomy.

Perfusionist are credentialed in The United States by the American Board of Cardiovascular Perfusion, and obtains the Certified Clinical Perfusionist or CCP after completion of an accredited program in perfusion as well as a board examination.  Other countries have different requirements but most have formal training schools and testing.  All perfusionists work under the direction of a cardiovascular surgeon and communication between the surgeon and perfusionist is crucial throughout the entire surgery.

Most perfusionists are clinically involved with adult patient populations but there are also perfusionists which are affiliated with children hospitals and only perform CPB for children.  Perfusionist who travel with the Gift of Life, Inc. are all specialized in pediatric congenital heart surgery and bring a wealth of knowledge from different regions of the US.  Along with the other members of the open heart team perfusionist are a critical component to successful congenital open heart surgery.

Brian C. Forsberg, BS CCP-LP

Director of Perfusion

Dragos now has a bright future ahead of him and this is what our son is today and it is all thanks to you.

God bless you for what you are doing, and always realize that you bring smiles on other people’s faces and tears of joy in other grateful eyes.

Eternal gratitude,
Dragos, Marcel and Geta Tuluc, from Cluj-Napoca, Romania