1. Adult Perfusion, Present and Future Emad Kashmiri KFNGH

2. Adult P e rfusion – Present and Future Extracorporeal perfusion started in 1963,s Since that time many new medically valuable procedures and technologies have been developed and utilized by perfusionists. This dynamic field continues to develop and improve. perfusion as a profession.

3. Presently in developed countries, adult cardiac surgery is predominately focused on the treatment of coronary artery disease. The tremendous expansion in cardiac surgery is closely related to the prevalence of coronary heart disease and the ability to apply surgical palliation with ever decreasing risk.

4. Nowdays valve and Aortic surgery is not very common and some surgeons may only do a few cases a year. Treatments such as non-surgical (balloon) valvuloplasty further limit the number of procedures.

5. In spite of programs designed to reduce the risk factors for coronary heart disease, hypertension diet lack in physical exercise smoking obesity genetic factors. Coronary artery surgery is literally the sole operation that some surgeons perform in some centers.

6. About 800.000 coronary bypass procedures are presently performed every year worldwide.

7. It has been hypothesized that elimination of the heart lung machine will improve morbidity and mortality in these high-risk patients (1)

8. However, few studies (2) reported no significant reduction in morbidity with their OPCABG patients compared to standard CABG patients. They actually included some advantages for the standard CABG patients

9. hemodynamic stability better blood pressure regulation technically superior anastomosis due to bloodless and motionless environment, temperature control ability to perform complete myocardial revascularization(a).

10. Some of the potential advantages of using OPCABG: the avoidance of the aortic cross clamping earlier extubations shorter hospital stay, reduction in the need for blood transfusio lower incidence of arterial fibrillation decreased costs !!!!

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12. OPCABG disadvantages - The distal anastomosis - early graft occlusion due to increased platelet deposition at the anastomosis site. - a drop in blood pressure and cardiac output when the heart is elevated - resulting in hemodynamic instability. - require large volumes of intravenous fluid to maintain adequate arterial and pulmonary blood pressure. Trendelenburg position to augment ventricular filling administer low dose inotropes (4,5).

13. It is not always possible to perform complete revascularization due to hemodynamic instability or anatomy of the coronary arteries.

14. not recommended for OPCABG (a). intra-myocardial coronary arteries small coronary arteries inaccessible calcified coronary arteries disease through the length of the vessels with large hearts who do not tolerate manipulation

15. New procedures which support ventricular function such as implanted and external (percutaneous) LVAD’s, ECMO artificial hearts, etc. will continue to provide perfusionists with a rich learning environment and opportunity.

16. Off pump cases now and in the future will always require the presence of a perfusionist that is fully trained and capable of dealing with the very demanding emergencies that can arise during OPCABG.

17. The level of training and experience needed for dealing with such emergencies will insure that perfusionists will continue to have a critical role in all adult cardiac surgical procedures.