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Perfusion Glitches: Deprimed Cardioplegia Line


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Editors Note: This is a new Section. We are trying to develop a database of common or not-so-common problems encountered by perfusionists during CPB.

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Event Description:

Dear sir,

I recently encountered a problem with my cardioplegia line depriming following my initial arresting dose.

It was during the middle of the first distal anastamosis, and I took the clamp off of my cardioplegia line to reposition it. It immediately filled with air. I was shocked because the line was still occluded by the delivery system, so I thought perhaps my aortic root vent was on too high and had created a strong enough negative pressure to pull air out of solution (blood).

As it turned out, my luerlock connection was off by a pinprick- and just loose enough to pull air (negative pressure from vent line) through it when I momentarily moved my clamp.

I re-tightened the connection and I informed the surgeon. We reprimed the line by flushing the air out through the root vent.

Thank you for allowing me to share this event.


How Was The Problem Identified?

  • Watched the line deprime.

What Steps Were Taken ?

  1. Lines reconnected
  2. De-aired via AO root vent Issue Resolved

What Clues Were Missed?

  • None: Everything was double and triple checked.


  • First time I ever saw that happen.


  • No issues.


  • None

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