Old Faithful: A Great Customized Pediatric/Adult Recirculating Cardioplegia System Never Dies

Customization in pediatrics is very common.  Early in my career since the
early 80’s, there has been a lot of improvements in perfusion.  It has been a
long cry from the NS/LR with KCL & Bicarbonate myocardial protection to the
current single dosing formulas of the Rebeyka (up to 90 minutes), del Nido
(120-160 minute range) and the Grand-Daddy of them all since 1964, Bretschneider
(in the 200-250 minute range) cardioplegia (published in German by Sondergaard &
Senn. Langenbecks Archiv Fur Chirugie. 1967;319:661-5).  Man, those good old
days really weathered some rough times.  We also struggled with cardioplegia
systems until Ron Leonard from SARNS developed in 1991 the Conducer cardioplegia
heat exchanger with a 0.06 m2 and a 7 ml prime.  We acted quickly to customize
it.  The following demonstrates a low prime system Ron Gorney and I published in
1994 on JECT. 

To date, we still use it.  Although we are now in different institutions, the
basic setup remains.  Ron Gorney and Rich Ginther have presented it in various
meetings over the years as have I because we believe in its simplicity and
efficiency.  If you have a few minutes, recirculation simply guarantees the
desired temperatures.  Even today, some have even resorted to an additional heat
exchanger to achieve desired cardioplegia temperatures which shocked some of us
in the perfusion community.  Although, any heat exchanger would suffice, the
conducer will be shown for clinically acceptable circuits used in today’s
practice by some.  Keep in mind, that a Micro-bubble alarm is recommended over a
Macro-bubble alarm for obvious reasons because as you can see we do not utilize
a bubble trap.  In addition, with bubble traps are not an absolute in protection
because some still have still run dry and pumped air which re-enforces the
recommendation for a Micro-bubble alarm.  In the 80’s, 90’s and early 2000’s, we
used Macro-bubble alarms until the Micro-bubble alarms were available.

The key is to use large bore stopcocks either as a double or manifold for its
purpose.  The other ports are for infusion of blood or crystalloids (Fig. 1,
2).  The first one proximal port would be for pressure monitoring while the
adjacent one for infusion.  These large bore stopcocks have pressure drops under
100 mmHg at 200 ml/minute.  For larger patients, we use a luer connection
proximally to the stopcocks or a “Y” connector proximal to the stopcocks (Fig.
3,4) for lowering pressure drops and better flow dynamics.

Reservoirs can be a simple burette or Viaflexâ bags from 250, 500, 1000,
2000, 3000  to 4000 ml (Fig  5,6).  Figure 7 from the 90’s demonstrates a Abbott
250 ml burette (no longer made but one can use 150 ml burette) with a 4:1 ratio
Buckberg.  Figure 8 & 9 demonstrate both Rebeyka and del Nido blood cardioplegia
with Viaflexâ bags.  Figure 10 demonstrates Custodiolâ cardioplegia.

Any Ratio:  1:4, 1:2, 1:1, 4:1, 8:1 or Crystalloid can be used with this
setup.  Low prime re-circulating systems guarantees maximum hypothermia within
1-4 minutes depending on the volume in reservoir for any desired cardioplegia
temperature.  If you want try and scope it out, simply call you Terumo
Representative and ask for a few samples of my set-up (72716).  Again, this is
just one setup that we wanted to share because its concept is a good and
practical one and proven since the early 90’s.

A modification of the heat exchanger is required when a vertical manifold is
to be utilized (Figure right).  It’s fun modifying stuff.

Maybe old things are not so bad?  As Stan Fennig
used to say, “Everything goes in circles”.  Reminds one of the 1973 song by
Three Dog Night from, “Going in Circles”.

Jorge Molina, PA-C, CCP