Portable Coronary Active Perfusion System for

Off-Pump Coronary Artery Bypass Grafting

Yoshinao Koshida, MD, Go Watanabe, MD, Tamotsu Yasuda, MD,
Shigeyuki Tomita, MD, Shinichi Kadoya, MD, and Taro Kanamori, MD
Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine, Kanazawa, Ishikawa, Japan

Purpose. The present study was performed to develop a new perfusion system for
NEW TECHNOLOGY

off-pump coronary artery bypass grafting and to examine whether even a simple coronary
perfusion system can maintain adequate blood flow delivery during anastomosis.
Description. The experiment was performed in two stages. In procedure 1, 3 pigs with left
anterior descending artery occlusion were used to evaluate optimal perfusion flow rate and
coronary artery internal pressure, and to evaluate the safety area of perfusion. In procedure
2, 6 pigs were used to validate the new portable coronary perfusion system.
Evaluation. The optimal blood flow in the portable coronary active perfusion system was
less than approximately 40 mL/min. The small, easy to use pump system (ie, the portable
coronary active perfusion system) may prevent hemodynamic deterioration and ventricular
arrhythmia during coronary occlusion, resulting in better maintenance of left ventricular
function.
Conclusions. Even a simple pump system can achieve effective perfusion for safe
anastomosis. Further studies are required to allow the clinical use of this system.
(Ann Thorac Surg 2006;81:706 11)
2006 by The Society of Thoracic Surgeons

O ff-pump coronary artery bypass grafting (OPCABG)

is a promising technique for the treatment of
ischemic heart disease. However, one concern with
OPCABG is that temporary occlusion of the coronary
artery, which is frequently required during anastomosis
in OPCABG, can cause hemodynamic instability and
myocardial damage [1]. In addition, retraction and stabi-
lization maneuvers during OPCABG often cause sys-
temic hypotension, especially when the heart is displaced
vertically for exposure of its lateral and posterior
branches [2].
Several clinical studies have demonstrated the effec-
tiveness of intracoronary shunts, external shunt circuits,
or ischemic preconditioning procedures [3, 4] to reduce
ischemic injury. These methods are advantageous in
terms of both cost and time, and can be easily set up.
However, these methods have shown little or no effect in
patients with severe proximal coronary artery stenosis or
severe ischemic heart disease with low coronary pressure
and unstable flow. Moreover, it is unclear how the
adequacy of blood flow is affected by internal or external
shunts when systemic blood pressure deteriorates during
retraction or compression of the heart in OPCABG [5].
Accepted for publication June 22, 2005.
Address correspondence to Dr Koshida, 13-1 Takaramachi, Kanazawa,
920-8641 Japan; e-mail: yoshinaoko2000@yahoo.co.jp.
Technology and Technique
We recently developed the coronary active perfusion
system (CAPS) to avoid blood supply inadequacy in the
ischemic myocardium in OPCABG [6]. This is an active
perfusion technique in which oxygenated blood is sup-
plied from the femoral artery and pressurized by a pump
to optimize blood flow to the myocardium, and the
amount of blood supply is not dependent on hemody-
namic status during the procedure. However, CAPS
includes a special pump, controller, and power supply
system, and therefore is not easy to access, especially in
emergencies. For that reason, use of this procedure has
not yet become widespread.
We have developed a new perfusion system that may
enable active perfusion of arterial blood into the coronary
artery during coronary artery occlusion, and thus avoid
ischemic injury during the procedure. Moreover, the
apparatus required is small and simple in comparison
with other coronary perfusion systems [6 8]. Herein we
report details of our new method and describe experi-
ence with the new coronary perfusion system.
Clinical Experience
All animals received humane care in accordance with the
Principle of Laboratory Animal Care formulated by the
National Society for Medical Research and the Guide
for Care and Use of Laboratory Animals, prepared by

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00

Published by Elsevier Inc doi:10.1016/j.athoracsur.2005.06.064
Ann Thorac Surg
2006;81:706 11
the Institute of Laboratory Animal Resources, National
Research Council and published by the National Acad-
emy Press, revised in 1996.
Nine pigs were used in this study. All pigs were
sedated by intramuscular injection of ketamine (20
mg/kg body weight). Anesthesia was maintained with
halothane (0.5% to 1.5%), and muscle relaxation was
induced with pancuronium (0.1 mg/kg), which was ad-
ministered through the peripheral intravenous route.
An arterial pressure line was inserted into the brachio-
cephalic artery through the common carotid artery. A
Swan-Ganz catheter was inserted into the pulmonary
artery through the right internal jugular vein for pressure
monitoring and continuous cardiac output measurement
(IntelliCath CCO/VIP, SAT-2 [Deerfield, Baxter, IL]). A
4-French catheter was inserted into the right femoral
artery to remove arterial blood for the perfusion system.
The experiment consisted of two stages.
Procedure 1
In procedure 1, 3 left descending coronary artery oc-
cluded pigs were used to determine the optimal perfu-
sion flow rate. After systemic heparinization (200 u/kg),
the left descending coronary artery was snared at a point
just distal from the first diagonal branch, and a coronary
arteriotomy was performed. A pressure wire (WaveMap
[Endosonics, Rancho Cordova, CA]) and coronary perfu-
sion cannula were then inserted through the arteriotomy
site. To prevent escape of pressure from the arteriotomy
site, a site distal to that of arteriotomy was snared. The
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NEW PERFUSION SYSTEM FOR OPCABG
Fig 1. Measurement of coronary perfusion
flow and coronary arterial pressure during
coronary active perfusion. (A) Schematic pre-
sentation of perfusion circuit. (B) Efferent
pump and flow meter. (C) The CAPS can-
nula. (CAPS coronary active perfusion sys-
tem; LAD left anterior descending artery;
PCPS percutaneous cardiopulmonary
support.)
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resulting arterial blood passed through a modified per-
cutaneous cardiopulmonary support circuit with a cen-
trifugal pump (Mix Flow [JMS, Tokyo, Japan]) was led to
the installed inline electromagnetic flow probe (Nihon-
Kohden, Tokyo, Japan) in the last part of the circuit to
measure flow of coronary active perfusion (Fig 1). Coro-
nary perfusion flow was gradually increased in a step-
wise manner to determine how much flow it raised to
critical pressure and to evaluate the upper limit of
optimal perfusion flow.
Procedure 2
In procedure 2, 6 pigs were used to validate the new
coronary perfusion system, including cardiac function
during perfusion. The portable CAPS is shown in Figure
2. Arterial blood was passed through extension tubes and
was pumped out from the microdiaphragm pump (CM
15W Enomoto Micro Pump [Enomoto Kogyo, Tokyo,
Japan]). This pump system is small, simple, battery-
driven, and inexpensive. The pump and battery can be
placed in a small waterproof case and can be operated by
a surgeon alone without the assistance of a perfusionist.
This small pump can transfer liquid at a maximum rate of
100 mL/min. The approximate flow rate can be set using
the coronary perfusion cannula. The coronary cannula
used in the present study has already been applied in our
unit as previously reported [6, 7]. The enlarged fixed
portion of the cannula can prevent back bleeding from
the arteriotomy site by selecting a size of enlarged
portion suitable for each coronary artery. In this proce-
 708 NEW TECHNOLOGY KOSHIDA ET AL Ann Thorac Surg
NEW PERFUSION SYSTEM FOR OPCABG 2006;81:706 11

Fig 2. (A) Small diaphragm pump and motor

unit. (B) Portable coronary active perfusion
system (CAPS). (C) The CAPS cannula.
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dure, we used a cannula measuring 1.25 mm in external Results of Procedure 1

diameter and 0.8 mm in inner diameter. Coronary pressure increased proportionately with grad-
Coronary perfusion was performed for 30 minutes as ual increases in perfusion flow. Until a perfusion flow of 40
described in procedure 1, and hemodynamic and me- mL/min, the mean slope was expressed by Y 1.41X 22.1.
chanical data were recorded. Suitable portable CAPS However, with perfusion flow in excess of 40 mL/min, the
perfusion flow was set based on flow that did not surpass mean slope was greater than the values expected from
the upper limit set in procedure 1. A conductance cath- the perfusion flow until 40 mL (Y 6.66X 184; r 0.999;
eter (Conductance-PC software [Cardio Dynamics BV, p 0.01), and the increase in peripheral resistance
Zoetermeer, The Netherlands]) was used to evaluate left predicted endothelial injury (Fig 3). At a perfusion flow
ventricular function and mechanical data. Left ventricu- exceeding 60 mL/min, coronary pressure increased re-
lar contractility was quantified based on the slope of the gardless of changes in perfusion flow.
end systolic pressure-volume relation (end-systolic elas-
tance [Ees] [mm Hg/mL]). The endpoint of this study was
30 minutes of observation without ventricular arrhyth-
mia. At the end of the experiment, the pigs were given a
lethal intravenous injection of pentobarbital and potas-
sium chloride, and transmural samples of the left ven-
tricular anterior wall were taken for histologic
examination.
Statistical analyses were performed using SPSS for
Windows (version 10.1.3J [SPSS Inc, Chicago, IL]). Cu-
mulative data are expressed as means standard devi-
ation. Simple linear regression was used to analyze the
relationship between the perfusion flow rate and coro-
nary pressure. The paired t test was performed for
analysis of hemodynamics before and after the experi-
ments, and repeated analysis of variance was used for
analysis of changes in the hemodynamics, coronary ar- Fig 3. The relationship between perfusion flow and mean coronary
tery pressure, coronary perfusion flow, and Ees. artery pressure. Data are presented as means standard deviation.
Ann Thorac Surg NEW TECHNOLOGY KOSHIDA ET AL 709
2006;81:706 11 NEW PERFUSION SYSTEM FOR OPCABG

NEW TECHNOLOGY
Fig 4. Changes in mean arterial pressure (top). Changes in the slope Fig. 5. Changes in perfusion flow during the experiments (top).
of the end systolic pressure volume relation (Ees) during the experi- Changes in coronary pressure (bottom).
ments (bottom). Data are presented as means standard deviation.

indicated little flow with these methods. Muraki and

Results of Procedure 2 colleagues [5] reported that intracoronary shunts pro-
Ventricular arrhythmia was not observed in any of the vided only 10% 30% of baseline blood flow in dogs
pigs for 30 minutes. None of the hemodynamic variables even without stenosis of the coronary artery. Moreover, it
(ie, heart rate, aortic pressure, cardiac output) changed is unclear how the adequacy of blood flow is affected by
during the 30-minute observation period (Fig 4A). The internal or external shunts when systemic blood pressure
changes in Ees are shown in Figure 4B. The value of Ees deteriorates during retraction or compression of the
did not change significantly during the experiment. heart in OPCABG. Therefore, some active perfusion
Free flow was 35.8 1.16 mL/min. Perfusion flow was systems may be required to obtain stable flow.
30.5 3.50 mL/min, and the decrement in perfusion was
14.9%. Coronary pressure and perfusion flow rate during
the experiment are shown in Figure 5. The coronary
pressure was lower than that in procedure 1, and was not
greater than the physiologic range. Flow pattern was
slightly dominant in the diastric phase (Fig 6).
On pathologic examination none of the pigs showed
tissue edema or vessel injury. Endothelium cells were
well preserved at the coronary artery distal to the can-
nula tip.

Comment
Several methods have been developed for perfusion of
the coronary artery and to avoid myocardial ischemia
during OPCABG. The intracoronary shunt method and
external shunt circuit have been used extensively for this
purpose [3, 4]. These methods are advantageous with
regard to both cost and time because they are inexpen-
sive and can be easily set up as they do not require any
specialized apparatus. These two methods have the same Fig. 6. Waveform of coronary perfusion flow and electrocardiogram.
characteristics given that distal coronary bed perfusion The coronary active perfusion system pattern (upper). Electrocardio-
can be provided passively. However, several studies have gram (lower).
 710 NEW TECHNOLOGY KOSHIDA ET AL
NEW PERFUSION SYSTEM FOR OPCABG
To prevent myocardial ischemia during OPCABG, sev-
eral active perfusion methods have been reported. Mu-
raki and colleagues [8] investigated the efficacy of active
coronary perfusion with a nonpulsatile pump (perfusion-
assisted direct coronary artery bypass). Recently we re-
ported the CAPS to avoid inadequate blood supply for
ischemic myocardium [6, 7]. These procedures are active
perfusion techniques and have the characteristic that the
amount of blood supply does not depend on hemody-
namic status during the procedure. Vassiliades and col-
leagues [9] reported that active coronary perfusion using
an in-line pump resulted in superior myocardial protec-
NEW TECHNOLOGY
tion and performance during OPCABG as compared with
either no coronary perfusion or passive coronary perfu-
sion. However, these active perfusion systems have a
number of disadvantages in that they require large,
expensive, and complicated settings, and therefore these
systems have not yet gained widespread acceptance
among cardiac surgeons.
The diaphragm pump used in the present study was
able to supply a stable flow. In addition, this pump
system was small, inexpensive, and consumed little
power, and therefore could be driven by a small battery.
The flow rate controller was omitted to simplify the
system, but some flow rate adjustment was possible by
adjusting the inner diameter of the circuit. The flow
rate was set at approximately 30 mL/min, the value
determined by procedure 1, so that the coronary artery
pressure was maintained within the physiologic limits.
Simplification of the system prevents measurement of
coronary pressure, but if the coronary artery pressure
increases too much, excess blood over the lesional myo-
cardial demand may be washed away from the arteriot-
omy site. Therefore, it is important to select an appropri-
ate cannula size. Thus, critical high pressure does not
represent a significant concern.
The portable CAPS developed in the present study can
achieve adequate perfusion with a constant volume,
nonpulsatile pump. There have been few reports regard-
ing small pumps for coronary perfusion. A miniature
vibrating flow pump was reported for external shunt
catheter [10]. However, its clinical application has not
been reported yet. In future studies it will be necessary to
perform comparisons between our system and such a
small pump.
In conclusion, hemodynamic deterioration and ventric-
ular arrhythmias during coronary occlusion were pre-
vented by the portable CAPS. Even a simple pump
system can achieve effective perfusion. Further studies
including examination of adequate coronary active per-
INVITED COMMENTARY
This article [1] describes a novel active coronary perfu-
sion system for use in off-pump coronary artery bypass
(OPCAB) procedures. The authors tested this system in
normal in-situ porcine hearts. They demonstrated stable
electrophysiologic and contractile function for 30 minutes
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2006;81:706 11
fusion flow and pressure in humans are necessary to
allow clinical application of this system.
Disclosures and Freedom of Investigation
The microdiaphragm pump and catheter were purchased
by Kanazawa University. The authors have performed a
free and independent evaluation of this new technology.
The authors had full control of the design of the study,
methods used, outcome measurements, analysis of data,
and production of the written report.
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Disclaimer
The Society of Thoracic Surgeons, the Southern Thoracic
Surgical Association, and The Annals of Thoracic Surgery
neither endorse nor discourage use of the new technol-
ogy described in this article.
in myocardium perfused by their pump, and there was
no evidence of acute vascular injury from the intracoro-
nary cannula.
Other investigators have shown the potential for active
coronary perfusion systems to diminish ischemic injury
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.07.093