Principles of Principles of Cardiopulmonary bypassCardiopulmonary bypass

“Heart Lung Machine”“Heart Lung Machine”

Ida SimanjuntakIda SimanjuntakPerfusionist StaffPerfusionist Staff

National Cardiovascular Center Harapan National Cardiovascular Center Harapan KitaKita

Agustus 2012Agustus 2012

How it’s work ?How it’s work ?

DefinitionDefinition

Cardiopulmonary bypass(CPB) is a form Cardiopulmonary bypass(CPB) is a form of extracorporeal circulationof extracorporeal circulationIIt temporarily takes over the function of the t temporarily takes over the function of the heart and lungs during surgery, heart and lungs during surgery, maintaining the circulation of blood and maintaining the circulation of blood and the oxygen content of the bodythe oxygen content of the body

Tujuan Tujuan Umum Umum Cardio Pulmonary By PassCardio Pulmonary By Pass

1.1. Mempertahankan sirkulasi dan respirasi yang adekuat Mempertahankan sirkulasi dan respirasi yang adekuat dengan mengalirkan darah ke suatu sirkuit dengan mengalirkan darah ke suatu sirkuit extracorporal yang berfungsi sebagai jantung dan extracorporal yang berfungsi sebagai jantung dan paru.paru.

2. 2. Menciptakan lapangan operasi yang bersih dari darah. Menciptakan lapangan operasi yang bersih dari darah. Dengan cara Dengan cara mengalirkan darah keluar jantung mengalirkan darah keluar jantung dan menghisap darah yang masuk ke dan menghisap darah yang masuk ke jantung, jantung, sehingga dokter bedah dapat melakukan koreksi sehingga dokter bedah dapat melakukan koreksi pembedahan/ operasi dengan bebas. ( Jon W. Austin, pembedahan/ operasi dengan bebas. ( Jon W. Austin, 1986).1986).

Componen of Heart Componen of Heart Lung MachineLung Machine

PumpsPumpsCannulaCannulaReservoirReservoirOxygenatorOxygenatorHeat ExchangerHeat ExchangerArterial FilterArterial FilterAccessory pump & devicesAccessory pump & devices

PUMPPUMP

Centrifugal pump Roller Pump

Roller pumpRoller pump Centrifugal pumpCentrifugal pump

DescriptionDescription Nearly occlusiveNearly occlusive Non occlusiveNon occlusive

After load independentAfter load independent After load sensitiveAfter load sensitive

AdvantagesAdvantages Low prime volumeLow prime volume Portable, position insensitivePortable, position insensitive

Low costLow cost Safe positive and negative pressureSafe positive and negative pressure

No potential for backflowNo potential for backflow Adapts to venous returnAdapts to venous return

Shallow sine-wave pulseShallow sine-wave pulse Superior for right or left heart bypassSuperior for right or left heart bypass

Preferred for long-term bypassPreferred for long-term bypass

Protects against massive air embolismProtects against massive air embolism

DisadvantagesDisadvantages Excessive positive and negative pressureExcessive positive and negative pressure Large priming volumeLarge priming volume

SpallationSpallation Requires flow meterRequires flow meter

Tubing rupture, hemolysisTubing rupture, hemolysis Potential passive backward flowPotential passive backward flow

Potential for massive air embolismPotential for massive air embolism Higher costHigher cost

Necessary occlusion adjustmentsNecessary occlusion adjustments

Roller versus centrifugal pumpRoller versus centrifugal pump

Aorta CanullasAorta Canullas

Vena Vena Cannulas Cannulas VENOUS CANNULAS AND CANNULATIONVENOUS CANNULAS AND CANNULATION Three basic approaches for central venous cannulation Three basic approaches for central venous cannulation

are used: bicaval, single atrial, or cavoatrial ("two stage") are used: bicaval, single atrial, or cavoatrial ("two stage") At times, venous cannulation is accomplished via the At times, venous cannulation is accomplished via the

femoral or iliac vein. This either open or percutaneous femoral or iliac vein. This either open or percutaneous cannulation is used for emergency closed cannulation is used for emergency closed cardiopulmonary assist, for support of particularly ill cardiopulmonary assist, for support of particularly ill patients,reoperations.patients,reoperations.

Single Canul /Two Stage Double Canul( SVC, IVC Canul )

Femoral CannulaFemoral CannulaAortic: single outlet hole

Venous: multiple inlet holes

Level Detector (SAFETY)Level Detector (SAFETY)

Different ports and ManifoldDifferent ports and Manifold

BUBBLE DETECTORBUBBLE DETECTOR

can efficiently detect air embolisms between 10 and 250 μm in diameter, as well as simultaneously monitoring for micro bubbles

F I L T E R SF I L T E R S

PRINCIPLES OF VENOUS DRAINAGE

Venous blood usually enters the circuit by gravity or siphonage into a venous reservoir placed 40 to 70 cm below the level of the heart.“AUGMENTED OR ASSISTED VENOUS RETURN”

1919

Antegrade Cannula

CARDIOPLEGIA

Antegrade cardioplegia is delivered through a small cannula in the aortic root or via handheld cannulas directly into the coronary ostia when the aortic valve is exposed.

Pressure Antegrade150-200 mmHg (Perfusion)50-100 mmHg (Monitor)

Retrograde cardioplegia is delivered through a cuffed catheter inserted blindly into the coronary sinus. Proper placement of the retrograde catheter is critical, but not difficult, and is verified by palpation, TEE, color of the aspirated blood, or pressure waveform of a catheter pressure sensor. Complications of retrograde cardioplegia include rupture or perforation of the sinus, hematoma, and rupture of the catheter cuff

Retrograde CannulaPressure Retrograde

100-150 mmHg (Perfusion)30-50 mmHg (Monitor)

Vent CannulaVent Cannula

(A) Aortic root vent, which can also be used to administer cardioplegic solution after the ascending aorta is clamped. (B) A catheter placed in the right superior pulmonary vein/left atrial junction can be passed through the mitral valve into the left ventricle. (C) Direct venting of the left ventricle at the apex.(D) Venting the main pulmonary artery, which decompresses the left atrium because pulmonary veins lack valves.

OxygenatorOxygenatorOxygenation Two types of oxygenators are in current use: the bubble oxygenator and the more widely used mem- brane oxygenator.

Both types usually have an integral heat exchanger to control the temperature of the blood

Membrane oxygenator with integral venous reservoir

OxygenatorOxygenator Studies have shown that membrane oxygenators are less traumatic

to blood components (e.g., platelets) and cause less blood loss and protein denaturization than bubble oxygenators (van Oeveren et al. 1985; Hill et al. 1985). Membrane oxygenators also provide sepa- rate control of oxygen and carbon dioxide, which is more difficult to obtain with bubble oxygenators. The indirect blood/gas interface also reduces the occurrence of microemboli (Toner et al. 1997).

Furthermore, mem- brane oxygenators require lower priming volumes and eliminate the need for defoaming devices or antifoam agents. However, despite the current preference for membrane oxygenators over bubble oxygenators, the effect of oxygenator type on clinical outcome is not completely certain. Although there is evidence that membrane oxygenators can reduce cerebral injury dur- ing cardiopulmonary bypass (Toner et al. 1997

HEMOFILTRATIONHEMOFILTRATION

Untuk mengurangi Untuk mengurangi HemodelusiHemodelusi

Filtrasi Cairan, Filtrasi Cairan, faktor inflamasi,faktor inflamasi, hiperkalemia atau hiperkalemia atau azotemiaazotemia

Diintegrasikan Diintegrasikan dengan sirkuit dengan sirkuit secara hati2 dan secara hati2 dan bebas Bubblebebas Bubble

Pre-BypassPre-Bypass

11.Begins with the posting of the operating schedule .Begins with the posting of the operating schedule Perfusionist must assemble specific information about Perfusionist must assemble specific information about

the scheduled procedurethe scheduled procedureSpecific information about the scheduled procedure : Specific information about the scheduled procedure :

Surgeon, patientSurgeon, patient’’s data, diagnoses, procedure, time s data, diagnoses, procedure, time of operationof operation

2. .Review of the patient2. .Review of the patient’’s hospital charts hospital chartInformation is recorded on the perfusion recordInformation is recorded on the perfusion record

3.Selection of the disposable equipment and perfusion circuit 3.Selection of the disposable equipment and perfusion circuit using existing protocolsusing existing protocols

4.Assembly of the cardiopulmonary bypass circuit4.Assembly of the cardiopulmonary bypass circuit5. Calculation of BSA, BV, cardiac indeks and blood flow5. Calculation of BSA, BV, cardiac indeks and blood flow6. Size of cannulae6. Size of cannulae7. Drug dose l and laboratories7. Drug dose l and laboratories8. Predicted hemoglobin and hematocrits8. Predicted hemoglobin and hematocrits9. Setting up the HLM & oxygenator9. Setting up the HLM & oxygenator10. Priming the oxygenator10. Priming the oxygenator11. Initiating CPB11. Initiating CPB12. Saffety device on 12. Saffety device on 13. Ice 13. Ice

Dr Gibbon’s early heart/lung machine

Gibbon JH et al. Arch Surg 1937; 34: 1109

PrimingPriming

Filling the CPB circuit with blood or blood Filling the CPB circuit with blood or blood substitutes after CO2 Flushingsubstitutes after CO2 FlushingResult in hemodilutionResult in hemodilution

HemodilutionHemodilution

PtPt’’s Blood Volume s Blood Volume Predicted Hct Predicted Hct

Pre-CPB IV + CPB prime volumePre-CPB IV + CPB prime volumeTarget: < 30% at BT below 30℃Target: < 30% at BT below 30℃

< 25% when BT below 25℃< 25% when BT below 25℃ not below 20%not below 20%

Hindari Hct intra CPB < 18 % HctHindari Hct intra CPB < 18 % HctUntuk memastikan Hct ketika inisiasi CPB:Untuk memastikan Hct ketika inisiasi CPB:

Hctint = initial Hct on CPBHctint = initial Hct on CPB EBV = estimated patient blood volumeEBV = estimated patient blood volume Hct = preoperative HctHct = preoperative Hct

Jika diperlukan penambahan RBC maka bisa dikalkulasi dengan :Jika diperlukan penambahan RBC maka bisa dikalkulasi dengan :

PBV = patientPBV = patient’’s blood volumes blood volume ECCV = extracorporeal circuit volumeECCV = extracorporeal circuit volume CPBHct = desired Hct on CPBCPBHct = desired Hct on CPB PtHct = patientPtHct = patient’’s pre CPB Hcts pre CPB Hct

Initiating CPBInitiating CPB

““Lines downLines down”” connects between table lines & pump connects between table lines & pump lines (in a sterile manner) lines (in a sterile manner) Debubble Debubble

Surgeon : Surgeon : ““Heparin inHeparin in”” Anesthesiologist give heparin Anesthesiologist give heparin ACT check. ACT check. ““Speed up (speedy)Speed up (speedy)”” fast circulating the priming fast circulating the priming

solutions, make sure no bubble exist.solutions, make sure no bubble exist. ““StopStop”” debubbling stopped, venous lines clamped. debubbling stopped, venous lines clamped.

Surgeons prepare to do cannulationSurgeons prepare to do cannulation ACT > 300 sec ACT > 300 sec Pump suckers on Pump suckers on

right debubbling ???right debubbling ???

Insert drugs and manitolInsert drugs and manitol Resirculated of the priming solution Resirculated of the priming solution Oksigen on Oksigen on Before cannulation of the aortic cannula, surgeon will Before cannulation of the aortic cannula, surgeon will

ask the perfusionist to roll forward, to fill in the tubing ask the perfusionist to roll forward, to fill in the tubing with priming solution and to make sure no bubble with priming solution and to make sure no bubble exist.exist.

Reply : Reply : ““ForwardForward””.... After the aortic cannula is unclamp, surgeon : After the aortic cannula is unclamp, surgeon : ““Open to Open to

youyou””. . Reply : Reply : ““Open/OkOpen/Ok””, check the pressure fluctuation on , check the pressure fluctuation on

the pressure module of the pump. the pressure module of the pump. Inform surgeon. Feel for pulsation the arterial line Inform surgeon. Feel for pulsation the arterial line

tubingtubing ACT > 480 ready to on bypassACT > 480 ready to on bypass

Continous Monitoring During CPBContinous Monitoring During CPB

Reservoir levelReservoir level Blood flow at proper rate/flow rateBlood flow at proper rate/flow rate Pressure line/arterial line pressurePressure line/arterial line pressure Blood pressure/patientBlood pressure/patient’’s arterial pressure 50-90 s arterial pressure 50-90

mmHgmmHg Oxigen saturationOxigen saturation Temperature appropriateTemperature appropriate ECGECG Venous oksigen saturation 65%-75%Venous oksigen saturation 65%-75%

Monitoring Blood pressureMonitoring Blood pressure

MAP: in mild to moderate hypothermiaMAP: in mild to moderate hypothermia normal adult: 60-70 mmHgnormal adult: 60-70 mmHg adult with CAD, DM, and old age: > 60mmHgadult with CAD, DM, and old age: > 60mmHg infants: > 60mmHginfants: > 60mmHg

CVP: approximate 0 mmHgCVP: approximate 0 mmHg

Pump Flow RatePump Flow Rate

In the normal body temperatureIn the normal body temperature adult: 2.2~2.8 L /madult: 2.2~2.8 L /m22 ．． minmin infant: 2.6~3.2 L /minfant: 2.6~3.2 L /m22 ．． minmin

In hypothermiaIn hypothermia adult: 1.6~2.2 L /madult: 1.6~2.2 L /m22 ．． minmin Infant: 2.0~2.4 L /mInfant: 2.0~2.4 L /m22 ．． minmin

Adjust according MAP and SvOAdjust according MAP and SvO22

Monitoring pressureMonitoring pressureCauses of aortic cannula high line pressureCauses of aortic cannula high line pressure

1. Kink in arterial cannula or line1. Kink in arterial cannula or line2. Cannula improperly positioned2. Cannula improperly positioned3. Clamp too near cannula3. Clamp too near cannula4. Cannula to small4. Cannula to small5. Arterial systemic blood pressure very high5. Arterial systemic blood pressure very high6. Aortic disection6. Aortic disection7. Blockage in arterial filter 7. Blockage in arterial filter

Monitoring Venous DrainMonitoring Venous DrainCauses of Poor Venous returnCauses of Poor Venous return

Intermittent Monitoring During Intermittent Monitoring During CPB CPB

blood gasblood gasUrine output minimal 0,5-1 ml/kgBB/jamUrine output minimal 0,5-1 ml/kgBB/jamelectrolitelectrolitACT > 480 secACT > 480 sec

Monitoring DevicesMonitoring DevicesMonitoring secara Monitoring secara

kontinue : SVO2, kontinue : SVO2, Suhu vena, HctSuhu vena, Hct

ACT > 480 secACT > 480 secCek ACT dan AGD Cek ACT dan AGD

setiap 30 – 60 menit setiap 30 – 60 menit jika stabiljika stabil

Monitoring Blood GasMonitoring Blood Gas

Coagulation Status and Laboratory Coagulation Status and Laboratory DataDataMenggunakan ACT untuk evaluasi status Menggunakan ACT untuk evaluasi status

koagulasikoagulasiHb 7,0 – 9,0 gr%Hb 7,0 – 9,0 gr%Ht 20 – 30 %Ht 20 – 30 %pO2 arterial AGD : 140-180 mmHgpO2 arterial AGD : 140-180 mmHgpCO2 arterial AGD : 31 – 45 mmHgpCO2 arterial AGD : 31 – 45 mmHgBE (-2,5) – (+ 2,5)BE (-2,5) – (+ 2,5)

Monitoring Urine OutputMonitoring Urine Output

Urinary volume and renal functionUrinary volume and renal functionDipengaruhi waktu bypass dan gagal Dipengaruhi waktu bypass dan gagal

ginjal sebelumnyaginjal sebelumnyaVolume urine 0,5-1 mL/kg/jamVolume urine 0,5-1 mL/kg/jamOligouria / normal + hiperkalemia, Oligouria / normal + hiperkalemia,

hemoglobinemia, hemodilusi berlebihan hemoglobinemia, hemodilusi berlebihan = indikasi diuretik= indikasi diuretik

Causes of Urine ProductionCauses of Urine Production1.1. Kinked or disconnected Foley catheter or tubingKinked or disconnected Foley catheter or tubing2.2. Catheter with tip obstructed by gelCatheter with tip obstructed by gel3.3. Decreased blood pressureDecreased blood pressure4.4. Low pump flowsLow pump flows5.5. Fluid moving to interstitial spaceFluid moving to interstitial space

Corrective ActionCorrective Action1.1. Straighten or connect tubingStraighten or connect tubing2.2. Push on bladderPush on bladder3.3. Give vasopressorGive vasopressor4.4. Increase flowsIncrease flows5.5. Use mannitol or lasixUse mannitol or lasix

HypothermiaHypothermia

Advantages:Advantages:decrease metabolic rate, oxygen decrease metabolic rate, oxygen requirementrequirementdecrease rate of degradative reactions, decrease rate of degradative reactions, increase tolerance to ischemiaincrease tolerance to ischemiareduces Kreduces K+ necessary for cardiac arrest necessary for cardiac arrestinhibits intracellular Cainhibits intracellular Ca2+2+ accumulation accumulation

HypothermiaHypothermia

Monitoring:Monitoring:Core temperature: nasopharyngeal or Core temperature: nasopharyngeal or tympanic membrane probes reflect brain tympanic membrane probes reflect brain temperaturetemperatureShell temperature: rectal probe or skeletal Shell temperature: rectal probe or skeletal muscle needle sensor reflect relatively muscle needle sensor reflect relatively pooly perfused tissues of most of the pooly perfused tissues of most of the bodybody’’s masss mass

Temperature Cardiac Index FIO2 Gas/Blood Flow Ratio

37 C 2,4 L 0,80 1 : 1

34 C 2,2 L 0,70 0,8 : 1

30 C 2,0 L 0,65 0,7 : 1

28 C 1,8 L 0,60 0,6 : 1

22 C 1,6 L 0,50 0,5 : 1

Termination of CPBTermination of CPB Preparing for Separation (Rewarming)Preparing for Separation (Rewarming)

Hipotermia sedang (25-30Hipotermia sedang (25-30C) digunakan untuk C) digunakan untuk memperlambat rewarming. Hipotermia berat memperlambat rewarming. Hipotermia berat (16-25(16-25C) + circulatory arrest : operasi defek C) + circulatory arrest : operasi defek kongenital atau rekonstruksi arkus aortakongenital atau rekonstruksi arkus aorta

Kriteria rewarm : naso 37Kriteria rewarm : naso 37C, bladder/rectal 35C, bladder/rectal 35C C atau jempol kaki 30atau jempol kaki 30CC

Rewarm yang inadekuat mengakibatkan Rewarm yang inadekuat mengakibatkan penurunan suhu pasien 2-3penurunan suhu pasien 2-3C pasca CPB C pasca CPB sampai tiba di ICU sampai tiba di ICU mengigil, mengigil, VO2, VO2, gangguan irama jantung, gangguan irama jantung, PVR PVR

Termination of CPBTermination of CPB

LAMPS LAMPS Laboratory dataLaboratory data

pH, pCO2 darah arteripH, pCO2 darah arteri Acidosis Acidosis depressant fungsi myocardial, gangguan obat inotropic depressant fungsi myocardial, gangguan obat inotropic

SvO2, Ht, ACT, konsentrasi heparinSvO2, Ht, ACT, konsentrasi heparin Na, K, Ca, Na, K, Ca,

HyperK >6 mEq/L (gangguan konduksi, AV blok)HyperK >6 mEq/L (gangguan konduksi, AV blok) HypoK (gangguan irama ventrikel dan atrial)HypoK (gangguan irama ventrikel dan atrial) HypoCa akibat hemodilusi, albumin atau produk darah (+sitrat) HypoCa akibat hemodilusi, albumin atau produk darah (+sitrat)

CaCl2 3-5 mg/kg (memperbaiki kontraksi miocardial dan PVR)CaCl2 3-5 mg/kg (memperbaiki kontraksi miocardial dan PVR) Glucosa darah Glucosa darah insulin 10-20 unit iv + glukosa prn insulin 10-20 unit iv + glukosa prn

Termination of CPBTermination of CPB Anastesia/MachineAnastesia/Machine

Analgesia – supplemental opioidAnalgesia – supplemental opioid Amnesia – benzodiazepineAmnesia – benzodiazepine Muscle relaxant – prnMuscle relaxant – prn Airway and functional oxygen delivery systemAirway and functional oxygen delivery system

Anastesia machine on, Adequate oxygen supplyAnastesia machine on, Adequate oxygen supply Breathing circuit intact, ETT connectedBreathing circuit intact, ETT connected Ventilator functional, Ability to ventilate both lungs Ventilator functional, Ability to ventilate both lungs

confirmedconfirmed Vaporizers off (10 menit sebelum terminasi CPB) Vaporizers off (10 menit sebelum terminasi CPB)

untuk mengurangi efek depresi sirkulasi dan untuk mengurangi efek depresi sirkulasi dan menghindari depresi myocardial saat dilepas bypassmenghindari depresi myocardial saat dilepas bypass

Termination of CPBTermination of CPB MonitorsMonitors

Invasive BP monitors – zeroed & calibratedInvasive BP monitors – zeroed & calibrated Arterial catheter – radial, femoral, aorticArterial catheter – radial, femoral, aortic PAC, CVC (right atrial), left atrial catheterPAC, CVC (right atrial), left atrial catheter

ECGECG Kecepatan, irama, konduksi, iskemia (review semua lead)Kecepatan, irama, konduksi, iskemia (review semua lead)

Bladder catheter – urine outputBladder catheter – urine output Pulse oxymeterPulse oxymeter Capnometer/mass spectrometerCapnometer/mass spectrometer Safety monitor – oxygen analyzer, circuit pressure Safety monitor – oxygen analyzer, circuit pressure

alarm, spirometeralarm, spirometer TEETEE Temperature (37Temperature (37C nasofaringeal, 35C nasofaringeal, 35C rectal/bladder)C rectal/bladder)

Termination of CPBTermination of CPBPatient/PumpPatient/Pump

The HeartThe HeartCardiac function – contractility, sizeCardiac function – contractility, sizeRhythm, ventricular filling, air removed, vent Rhythm, ventricular filling, air removed, vent

removedremovedThe LungsThe Lungs

Inflation/deflation, complianceInflation/deflation, complianceThe FieldThe Field

bleedingbleedingOxygenation – blood colorOxygenation – blood colorMovement – sign of inadequate anasthesiaMovement – sign of inadequate anasthesia

Termination of CPBTermination of CPB SupportSupport

PharmacologicPharmacologic InotropesInotropes VasodilatorsVasodilators VasoconstrictiorsVasoconstrictiors AntidysrhythmicsAntidysrhythmics

ElectricalElectrical Atrial/Ventricular PacingAtrial/Ventricular Pacing

MechanicalMechanical Intraaortic Balloon CounterpulsationIntraaortic Balloon Counterpulsation Left and/or right ventricular assist deviceLeft and/or right ventricular assist device

Termination of CPBTermination of CPB

Separation TechniqueSeparation TechniqueCPB : (v. cavae CPB : (v. cavae oxygenator oxygenator aorta) aorta)Partial bypass : (v. cavae Partial bypass : (v. cavae oxygenator oxygenator

+ RV/lungs/LV + RV/lungs/LV common return to common return to aorta)aorta)

Off CPB : (v. cavae Off CPB : (v. cavae heart/lungs heart/lungs aorta)aorta)

After Termination of CPBAfter Termination of CPB

Setelah kanul aorta dilepas, sisa perfusate bisa Setelah kanul aorta dilepas, sisa perfusate bisa diproses kedalam kantung intravena sterile untuk diproses kedalam kantung intravena sterile untuk kebutuhan transfusi nantinya. Atau dengan alat cell kebutuhan transfusi nantinya. Atau dengan alat cell salvage sehingga darah dicuci dahulu sebelum salvage sehingga darah dicuci dahulu sebelum ditransfusiditransfusi

Pemberian protamine pada beberapa pasien Pemberian protamine pada beberapa pasien mengakibatkan penurunan hemodinamik mengakibatkan penurunan hemodinamik sementara. Perfusionis harus terus mengobservasi sementara. Perfusionis harus terus mengobservasi hemodinamik pasien dan menjaga sirkuit CPB tetap hemodinamik pasien dan menjaga sirkuit CPB tetap dapat digunakandapat digunakan

Daftar PustakaDaftar Pustaka http://www.cts.usc.edu/zglossary-heartlungmachine.html http://www.surgeryencyclopedia.com/Fi-La/Heart-Lung-Machines.ht

ml

Lippincott Williams & Wilkins 2007 Cardiopulmonary Bypass : Lippincott Williams & Wilkins 2007 Cardiopulmonary Bypass : Principles and PracticePrinciples and Practice

Cardiopulmonary Bypass: Principles and Management: Edited by Kenneth M. Taylor. 1998, Baltimore

On Bypass ,Advanced Perfusion Techniques Series: Current On Bypass ,Advanced Perfusion Techniques Series: Current Cardiac Surgery Mongero, Linda B.; Beck, James R. (Eds.) Cardiac Surgery Mongero, Linda B.; Beck, James R. (Eds.) 2008, 2008, XII, 576 p. 173 illus.XII, 576 p. 173 illus.

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