1. A Clinical Evaluation of Terumo’s Prescriptive Oxygenation™ Series Capiox® FX15 and FX25 Hollow Fiber oxygenators with Integrated Arterial Filter in the Adult Population
Ben Swanson, MPS, CCP
Staff Perfusionist
Associate Professor
University of Kansas Hospital
Center for Advanced Heart Care

2. Disclosure
I do not have a financial relationship with Terumo Cardiovascular Systems
The University of Kanas does not have a financial relationship nor partnership with Terumo Cardiovascular

3. Center for Advanced Heart Care
Ranked 39th in U.S. News and World Reports for Heart Care
Average 600 Heart cases per year
Started blood management program in 2009
Clinical affiliate for the University of Nebraska Medical Center’s Clinical Perfusion Education Program.
KCK, program was re-established about 10 years ago. Blood management program started in 2009, Min-invasive MVR, Per AVR

4. Position on Blood Management
Building an organization for “good success” means creating a culture that will live on through succeeding generation
Tony Dungy

5. Position on Blood Management
This is one part of blood management
Without all parts of a multidisciplinary program working, reducing prime volume is a mood point

6. Purpose Evaluate device and system Is it a cost effective alternative?
Should we continue to use it?
Will it work?
What effect if any will it have on blood product usage?

7. Prescriptive Oxygenation
Being able to match oxygenator to patient, similar to pediatrics
Reduced prime volume for patient with low body weight
Intergraded arterial filter allows even lower prime and surface area
Terumo FX15 and FX25

8. Specifications FX15 R40 Bundle fiber surface area 1.5 m2
Prime 144 mL, Maximum Flow 5.0 L/min.,
Integrated Arterial 32 micron filter,
Surface Area 360 cm2
Blood inlet pressure 1000 mmHg max
Heat-exchanger surface area .14 m2

9. Specifications FX25 Bundle fiber surface area 2.5 m2
Prime 260 mL, Maximum Flow 7.0 L/min.,
Integrated 32 micron Arterial Filter
Surface Area 600 cm2
Blood inlet pressure 1000 mmHg max
Heat-exchanger surface area .2 m2
Preferred in DCHA cases

10. Clinical Significance
The 2011 level (1A) recommendations from the Society of Thoracic Surgeons (STS)1
Reduce prime volume and surface area
Identify high risk patients / prepare accordingly
Previous studies have determined that a reduction in surface area–priming volume of the CPB circuit reduces the frequency of low HCT values and subsequently reduces the incidence of allogeneic blood transfusions 2
1. Frerraris, et al Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines. Ann Thorac Surg 2011;91:944-82
2. Shann, et al. Focus on neurologic injury, glycemic control, hemodilution, and the inflammatory An evidence-based review of the practice of cardiopulmonary bypass in adults: J Thorac Cardiovasc Surg 2006;132:

11. Clinical Significance
DeFoe and colleagues reported results from a multicenter study of 6980 patients undergoing isolated CABG surgery.
Patients experiencing a single HCT value of 19% or less during CPB had more than twice the mortality as patients with a nadir HCT value of 25%.
Furthermore, the lowest HCT value during CPB was significantly associated with increased intraoperative or postoperative placement of an intra-aortic balloon pump and return to CPB after attempted separation.
DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Ann Thorac Surg 2001;71:769 –76.

12. Clinical Significance
Habib et al. retrospectively analyzed 5000 patients undergoing cardiac operations with CPB
Stroke, myocardial infarction, low cardiac output, cardiac arrest, renal failure, prolonged ventilation, pulmonary edema, reoperation caused by bleeding, sepsis, and multi-organ failure were all significantly and systematically increased as the lowest HCT value decreased to less than 22%.
Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 2003;125:1438 –50.
Karkouti et al. analyzed 9080 consecutive patients undergoing cardiac operations with CPB and found an independent and nonlinear relationship between the nadir HCT value during CPB and acute renal failure, necessitating dialysis support.
Nadir hematocrit concentration <21%
The Journal of Thoracic and Cardiovascular Surgery Volume 129, Number 2 391

13. Study Design and Methods
This was a clinical, non-randomized retrospective evaluation of the Terumo® Capiox® FX15 and FX25 series oxygenators for
242 cases requiring CPB with accordance to institutional protocol
Isolated CABG, AVR, MVR
Efficacy in priming
Gas exchange
Oxygen delivery
Patient selection bias for either FX unit.
Blood conservation
All blood products
Strait forward CABG, same as STS data collection

14. Why not only Red Cells Reduction in surface area
Effect of hemodilution on coagulation

15. Methods Normothermia maintained on bypass
Appropriate perfusion adequacy parameters were established
Samples
Just prior to initiation of CPB
taken approx. 5-8 min post initiation of CPB
After initial dose of cardioplegia
i-stat blood gas POC device
Perfusion parameters had been optimized

31. Discussion The FX series was remarkably efficient in priming
Absence of CO2 flushing and
De-airing of an arterial line filter
The effect of the integral arterial filter on ventilation and gas exchange was minimal
Optimal PCO2 levels were achieved at sweep ratios between of .8-1
Comparable PO2 levels at 100% FIO2.
Early issues with FX 25 unit
Recommended to prime a 4-5 L/min with all shunts open to easily remove air from the integrated unit

32. Discussion
Markedly, the FX15 performed optimally above and at the limit of its manufacturer’s recommended flow rates
Rendering it the preferred oxygenator of choice even in larger patients that we may have previously used a FX25 when considering the reduction in prime

33. Discussion Selection Bias
Decidedly, body surface area (BSA) was the most
constraining factor when it came to patient selection
Age
Complexity of surgery and sex.
However, in borderline patients, BSA 2.0(±.2) m2, a reverse relationship between BSA and age was observed, based on metabolic demands, advanced aged patients trended towards the FX15 while the FX25 was preferred for younger patients.

34. Summary
Decreased prime volumes increased on pump Hct respectively in FX15 and FX25 units
However, more pronounced in smaller patients
Decrease in blood usage in isolated CABG’s for all 2010 when compared to 2009
Marketable decrease in blood usage in isolated valve procedures
AVR intra-op/post-op MVR intra-op/post-op
Specific to time in pump run, more of a trended increase than a certain number

35. Concerns / Future Directions
Hard to distinct reduction in prime is the sole reason for reduced blood product usage, without randomized prospective study
However, data does suggest that It most likely contributed
Improvements in decreased morbidity and mortality are still being investigated
Ordering issues
Not just one type, try not to run out of 25s

36. Conclusion
Terumo® Capiox® FX15 and FX25 series oxygenators are extremely safe and effective adjuncts to our previous system, and are able to reduce prime volume and surface area
Thus, have the potential to reduce of blood transfusions intra and post operatively
Especially in patients under 65 kg

37. Special Thanks University of Kansas Perfusion Staff
Carrie Kilgore, STS database coordinator
AmSECT
They made it all work

38. Thank You
Questions?
Feel free to contact me anytime