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2013 ; 45
(2
): 128-32
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Vacuum assist: angel or demon CON
#MMPMID23930383
Willcox TW
J Extra Corpor Technol
2013[Jun]; 45
(2
): 128-32
PMID23930383
show ga
Vacuum-assisted venous drainage (VAVD) to enhance venous return during
cardiopulmonary bypass (CPB) was described as early as 1958 but was not widely
used until the late 1990s. VAVD was initially used to facilitate the use of
smaller cannulas with ministernotomy but was increasingly used to allow reduction
in CPB circuit size while maintaining CPB flow rates. This innovation was made
without planned consideration to CPB circuit design, most critically that of the
venous reservoir. Clinical reports of prime reduction facilitated by VAVD in both
adult and pediatric CPB were associated with reduced nadir hematocrit and rates
of transfusion that encouraged the proliferation of VAVD in CPB. Concomitantly,
investigators have reported both in vitro and in vivo significantly increased
arterial emboli associated with the use of VAVD, mostly related to accelerated
venous air entrainment. In vitro studies continue to confirm this association and
likely underestimate the resulting embolic load as a result of flawed study
design. While the evidence for VAVD is equivocal, our understanding of the
clinical impact of gaseous microemboli in CPB is similarly limited, most likely
confined to blood-brain barrier disruption. It is only after two decades that CPB
component design is receiving serious attention in terms of air handling. The
ethics of innovation in the field of CPB warrant careful consideration. The
application of VAVD is not without consequence.