Cannula Tip Research Articles

Needle tip deformation in local dental anesthesia – A technical note

The aim of this in vitro study was to investigate the mechanical deformation rate of dental cannula tips after injection simulation in a new developed animal model. A new mechanical device was designed to define forces (100g for 60s) to impact a pigs jaw bone with different cannulas (25-Gauge/27-Gauge) from dental local anaesthesia syringes. 8 different products (100 cannulas each) were evaluated. Cannula tips were examined for deformation under the digital microscope VHX-100 (500-fold magnification). 27G and 27G free flow showed a significantly lower likelihood of bending (OR 0.05; p=0.0001). Comparing 27G cannulas of the same outer diameter but different inner diameter, large inner diameter produced a significantly higher deformation rate than those of cannulas with a standard inner diameter. 12-38% of the cannulas showed manufacturing defects and production-related deformation. Cannula deformation seems to depend on the inner diameter, bevel and cutting profile. Multiple use of the same cannula could result in more pronounced deformation, increasing the risk of complications during local anesthesia.

Case Report: Stemi With Covid-19

BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) causing coronavirus disease 2019 (COVID-19) has reached pandemic levels by March 2020. Patients with cardiovascular disease, particularly with cardiac injury represent a vulnerable population and increased risk of mortality and morbidity. There is still no guidelines for management of cardiovascular disease during the COVID-19 pandemic. CASE ILLUSTRATION An unconscious 52-year-old male brought to ER with complaints of abdominal discomfort and nausea. The patient had a cardiac arrest in ER and ROSC was obtained. The patient was intubated ECG showed anterior STEMI and primary PCI was performed. The endotracheal tube was changed due to blockage of excessive and thick slime. Tracheostomy was performed. Bronchoscopy was performed and found tracheal mucosal edema, hyperemic and easily bleed; mucous plug and blood clots in the tip of tracheostomy cannula. Thoracic CT-Scan showed ground-glass appearance and fibrosis of the 6th thoracic dextra segment. PCR SARS-CoV-2 showed reactive. The patient was discharged from our hospital after three weeks with clinically stable and referred to COVID-19 center hospital nearby his home for another two weeks. After PCR SARS CoV-2 was performed twice showed negative results, the patient was discharged. CONCLUSION SARS-CoV‑2 infection may lead to acute myocardial injury through viral systemic inflammation, although specific mechanism remained uncertain. A thick mucus plaque and stool cell may be a specific clinical features in COVID-19 patients. Tracheostomy has a continuing role in managing weaning from extended periods of mechanical ventilation during the COVID-19 pandemic.

A simplified method for bronchoalveolar lavage in mice by orotracheal intubation avoiding tracheotomy.

Bronchoalveolar lavage (BAL) represents an important method to sample immune cells and soluble substances from the lungs of humans and animals suffering from respiratory disease. The mouse is the most commonly used model organism to study lung disease. Performing BAL in mice is difficult due to their small size and the currently used method requires tracheotomy, a complex and time-consuming procedure. Here, we describe a simple alternative procedure thatavoids this step. To perform the BAL, a rigid, olive tip cannula is inserted from the mouth into the trachea under visual inspection. This novel method requires minimal training, is simple, fast, inexpensive and should be useful for researchers studying mouse models of human lung disease.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Extracorporeal Membrane Oxygenation Cannula-Related Infections: Epidemiology and Risk Factors.

Although being a potential major source of infection in extracorporeal membrane oxygenation (ECMO) patients, data regarding cannula-related infections (CRI) remain scarce. We therefore aimed at describing the epidemiology of CRI among critically ill patients supported by ECMO. Between October 2017 and November 2019, adult patients supported by either venoarterial (VA), venopulmonary arterial, or venovenous (VV) ECMO for more than 24 hours were prospectively enrolled. When CRI was suspected, cannula swab and subcutaneous needle aspirate samples were obtained for microbiological culture. Cannula tips were systematically sent for culture at the time of ECMO removal. Primary end-point was CRI, which was defined by sepsis or local sign of cannula infection and at least one positive culture among swab, subcutaneous needle aspirate or tip. Multivariate analysis was performed to identify risk factors of CRI. Hundred patients were included, including 77 VA, 12 venopulmonary arterial, and 11 VV ECMO. Cannula-related infections were diagnosed after a median duration of ECMO of 10 [7-13] days. Rate of CRI was 24%, including 10% with bacteremia. Most frequent involved pathogens were Enterobacteriaceae (n = 14), Enterococci (n = 8), and coagulase-negative Staphylococci (n = 7). By multivariate analysis, diabetes and ECMO duration were independently associated with CRI.

Modified technique of intralesional radiofrequency with drug deposition in keloids using customized intravenous cannulas

Intralesional radiofrequency using intravenous canula (IVC) is a commonly used procedure for selective ablation of dermal and subcutaneous lesions, while sparing the epidermis. 1 Subhadarshani S. Gupta V. Taneja N. Yadav S. Gupta S. Efficacy and safety of a novel method of insulated intralesional radiofrequency ablation for deep dermal and subcutaneous lesions: a 3-year institutional experience. Dermatol Surg. 2018; 44: 714-720 Crossref PubMed Scopus (7) Google Scholar In this procedure, an IVC is inserted into the depth of the lesion, and energy is delivered at the tip of the inner metallic cannula, which dissipates in all the directions. However, it may cause damage to the surface epithelium (Fig 1, A) when the dermal pathology is close to the epidermis (eg, keloid), resulting in slow healing, bad esthetic outcome, and risk of recurrence and scarring.

Cosmetic Breast Augmentation Using Power-Assisted Liposuction and Lipofilling: A Prospective Study.

Autologous fat transfer is becoming a more and more widespread procedure in aesthetic breast surgery. Power-assisted technology produces oscillating reciprocal movements of cannula tip, which reproduce the motion of the operator's arm with lower amplitude. The power-assisted mechanism can be applied to the fat liposuction and injection phases. The aim of this study is to report our experience on autologous fat transfer in primary cosmetic breast augmentation using power-assisted liposuction and lipofilling (PALL), our surgical technique and on long-term cosmetic results, and patient-reported outcomes. A prospective observational study was performed including all patients who underwent PALL cosmetic breast augmentation. Collected data included patient's age, BMI, mean liposuction and fat injection volume, mean operating time, postoperative complications, mean number of grafting procedures required to achieve the desired outcome, cosmetic results and patient satisfaction. A total of 43 patients were included with a mean follow-up of 13.32 months. Mean liposuction and injection volumes were 1884.54 mL and 399.03 mL, respectively. Mean number of grafting procedures was 1.27. With respect to aesthetic outcomes, the mean score for breast volume, shape, symmetry and donor site shape was 4.38, 4.22, 4.27 and 4.42, respectively. Regarding patient satisfaction, the mean score for breast volume, shape, symmetry and donor site shape was 4.22, 5, 5 and 4.77, respectively. The current study is the first prospective report on primary cosmetic breast augmentation using PALL. Although our sample of patients is limited, our results showed that PALL primary breast augmentation is an efficient procedure, which leads to satisfactory results for both patients and surgeons. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Novel Fat Making Strategy With Adipose-Derived Progenitor Cell-Enriched Fat Improves Fat Graft Survival.

A low survival rate is one of the main challenges in fat grafting. This study aimed to evaluate whether microfat obtained by a novel strategy promoted the survival and retention of fat grafts. A 5-mm-diameter blunt tip cannula with large side holes (~30 mm2/hole) was used to obtain macrofat. A novel strategy based on a newly invented extracorporeal cutting device was then used to cut the macrofat into microfat, which was named adipose-derived progenitor cell enrichment fat (AER fat); Coleman fat was used as the control. Aliquots (0.5 mL) of both types of fat were transplanted into 10 nude mice and analyzed 10 weeks later. Western blotting, flow cytometry, and immunofluorescence were performed to assess the AER fat characteristics and underlying mechanisms. The retention rate of fat grafts in AER fat-treated animals was significantly higher than that in the Coleman group (mean [standard deviation] 54.6% [13%] vs 34.8% [9%]; P < 0.05) after 10 weeks. AER fat contained more dipeptidyl peptidase-4-expressing progenitor cells (3.3 [0.61] × 103 vs 2.0 [0.46] × 103 cells/mL; P < 0.05), adipose-derived plastic-adherent cells (6.0 [1.10] × 104 vs 2.6 [0.17] × 104 cells/mL; P < 0.001), and viable adipocytes than Coleman fat. Moreover, histologic analysis showed that AER fat grafts had better histologic structure and higher capillary density. AER fat transplantation is a potential strategy to improve the survival and long-term retention of fat grafts. AER fat contained more dipeptidyl peptidase-4-expressing progenitor cells.

Directing a dispersion cannula tip toward the aortic root during thoracic aortic arch surgery does not adversely affect cardiac function.

Neurologic complications of open thoracic aortic surgery are devastating problems in patients with severely diseased aortas. This study aimed to clarify whether directing the aortic cannula tip toward the aortic root affects the postoperative cardiac function in patients undergoing open thoracic aortic surgery. A total of 16 patients who underwent total or partial arch replacement between January 2014 and April 2019 were enrolled and divided into two groups. Ascending aorta perfusion was performed by placing the cannula tip toward the aortic root (reversed direction group, seven patients) or toward the aortic arch (standard direction group, nine patients). Intraoperative and perioperative data, including mortality, morbidity, and postoperative cardiac function, were compared between the groups. There were no hospital deaths or stroke events in either group. The aortic cross-clamping time was 102.4 ± 20.3 minutes in the reversed direction group and 87.1 ± 9.9 minutes in the standard direction group (p = 0.049). Furthermore, the intubation time was 28.4 ± 12.9 hours in the reversed direction group and 12.4 ± 6.8 hours in the standard direction group (p = 0.022). Both times were significantly longer in the reverse direction group. Postoperative serum creatine kinase-MB levels were significantly lower in the reversed direction group (6.2 ± 3.3 U/L vs 13.3 ± 4.8 U/L, respectively, p = 0.006). The cardiac output and cardiac index did not significantly differ. Directing the aortic cannula tip toward the aortic root does not adversely affect the postoperative cardiac function after aortic arch surgery.

Flow analysis during mock circulation in normal and aortic arch aneurysm models through an aortic cannula toward the aortic arch and root.

The aim of this study was to elucidate flow patterns of two different types of aortic cannulas inserted from the ascending aorta toward the aortic arch and root by mock circulation in a normal aortic arch and an aortic arch aneurysm model. Extracorporeal circulation was established using a centrifugal pump, a transparent glass normal aortic arch model, and an aortic arch aneurysm model for measurement by particle image velocimetry. The Stealthflow and Dispersion cannulas were used to elucidate the characteristics of the flow pattern and velocity under the condition of the cannula tip toward the aortic arch and aortic root. In the normal aortic arch model, high-velocity exit flow ranging from 0.7 to 0.8m/s was detected in the proximal aortic arch by directing the cannula tip toward the aortic arch, whereas flow velocity in the aortic arch was < 0.2m/s by directing the cannula tip toward the aortic root. In the aortic arch aneurysm model, high-velocity exit flow ranging from 0.5 to 0.8m/s was detected in the aortic arch by directing the cannula tip toward the aortic arch, whereas flow velocity in the aortic arch was decreased to less than 0.2m/s by directing the cannula tip toward the aortic root. Directing the aortic cannula tip toward the aortic root allowed the high-velocity exit flow to attenuate in velocity, so that flow velocity in the aortic arch was sufficiently reduced by reversed flow and vortex formation in both the normal and aortic arch aneurysm models.

Improved Drainage Cannula Design to Reduce Thrombosis in Veno-Arterial Extracorporeal Membrane Oxygenation.

Thrombosis is a potentially life-threatening complication in veno-arterial extracorporeal membrane oxygenation (ECMO) circuits, which may originate from the drainage cannula due to unfavorable blood flow dynamics. This study aims to numerically investigate the effect of cannula design parameters on local fluid dynamics, and thus thrombosis potential, within ECMO drainage cannulas. A control cannula based on the geometry of a 17 Fr Medtronic drainage cannula concentrically placed in an idealized, rigid-walled geometry of the right atrium and superior and inferior vena cava was numerically modeled. Simulated flow dynamics in the control cannula were systematically compared with 10 unique cannula designs which incorporated changes to side hole diameter, the spacing between side holes, and side hole angles. Local blood velocities, maximum wall shear stress (WSS), and blood residence time were used to predict the risk of thrombosis. Numerical results were experimentally validated using particle image velocimetry. The control cannula exhibited low blood velocities (59 mm/s) at the cannula tip, which may promote thrombosis. Through a reduction in the side hole diameter (2 mm), the spacing between the side holes (3 mm) and alteration in the side hole angle (30° relative to the flow direction), WSS was reduced by 52%, and cannula tip blood velocity was increased by 560% compared to the control cannula. This study suggests that simple geometrical changes can significantly alter the risk of thrombosis in ECMO drainage cannulas.

Point-of-care ultrasound for the evaluation of venous cannula position in neonatal extracorporeal membrane oxygenation.

To assess the ability of point-of-care ultrasound (POCUS) to identify venous cannula position in neonates on extracorporeal membrane oxygenation (ECMO) and compare withconventional imaging. Retrospective review of 37 infants on ECMO with 51 POCUS studies between January 2017 and October 2019. Studies were reviewed for identification of venous cannula location and compared with plain radiography and echocardiography. Kappa statistic and predictive values were calculated. Venous cannula tip position was identified in 90% of POCUS studies. Fifty percent of the cannula tips were malpositioned. Plain radiography, the most commonly used method for evaluating tip position, showed poor agreement (57%) with POCUS (kappa 0.13). There was substantial agreement (89%) between echocardiography and POCUS (kappa 0.78). This study provides preliminary evidence that POCUS is more accurate than plain radiography for the evaluation of ECMO venous cannula position. Adoption of this practice may prevent potentially catastrophic ECMO complications.

Cannula breakage during 25G+ minimally invasive vitrectomy: a case report

BackgroundWith the continuous improvement of surgical instruments in vitrectomy, the use of a trocar and cannula not only optimizes the incision process but also facilitates insertion and withdrawal of instruments during the procedure. Nevertheless, incision-related complications have also been reported in the literature. However, cannula fractures during 25G+ minimally invasive vitrectomy have rarely been reported.Case presentationA 62-year-old man underwent 25G+ pars plana vitrectomy for proliferative diabetic retinopathy. At the beginning of the operation, we used a trocar with a cannula to perform the sclerotomy. After the trocar was pulled out, the cannula was not seen on the surface of the sclera. Thus the inside and outside of the eye were carefully searched. The broken cannula tip was found in the ciliary body corresponding to the superonasal sclerotomy site and was subsequently removed.ConclusionsAwareness regarding the risk of intraoperative fractures of 25G+ minimally invasive ocular surgical instruments is imperative. Whenever a broken or missing cannula is encountered, the residual part should be immediately extracted to avoid revision surgeries and postoperative complications.

Using Aortic Arch Short Axis Views during Transesophageal Echocardiographic Examination Facilitates Right Ventricular Assist Device Imaging

<h3>Introduction</h3> Recent increased utilization of percutaneous mechanical circulatory support for the management of cardiogenic shock and end-stage heart failure has resulted in the development and more widespread use of percutaneous right ventricular assist device (RVAD) technologies in right ventricular failure. RVADs require appropriate imaging to confirm correct positioning and ensure function. The proper imaging for this new technology has not been well described. We present two cases in which the upper esophageal (UE) aortic arch (AA) short-axis (SAX) view with transesophageal echocardiography (TEE) played an important role in RVAD management. <h3>Case Report</h3> <b>Case 1.</b> Device malposition: Four days after initial placement of a ProtekDuo cannula (CardiacAssist, Pittsburg, PA, USA) with extracorporeal RVAD under fluoroscopy, cannula malposition was noted intraoperatively. Under TEE UE AA SAX visualization, the cannula was advanced such that the tip remained in the main pulmonary artery throughout the cardiac cycle, ensuring proper flow (Figure 1A-C). <b>Case 2.</b> Device malfunction: One month after extracorporeal RVAD implantation, acute RVAD flow reduction and significant hemolysis were observed. The UE AA SAX view demonstrated thrombus formation on the tip of the RVAD outflow cannula (Figure 1D). The RVAD outflow cannula was exchanged surgically, and upon examination of the old cannula, the thrombus was noted to cause significant cannula exit obstruction. <h3>Summary</h3> These cases support the importance of the UE AA SAX TEE view in RVAD outflow imaging. When obtainable, this view should be included in routine RVAD assessment.

Single Uterine Access for Bilateral Pleuroamniotic Shunting in Fetuses with Severe Hydrothorax by an Internal Rotational Maneuver: Feasibility and Outcomes between Successful and Failed Procedures

Objective: The objective of this study was to describe the feasibility of single percutaneous uterine access for bilateral pleuroamniotic shunting (PAS) in fetuses with severe hydrothorax by using an internal rotational maneuver and to compare perinatal outcomes between successful and failed procedures. Methods: A prospective cohort of 25 fetuses with isolated bilateral hydrothorax and hydrops were referred to our fetal surgery center in Queretaro, Mexico during an 8-year period. Bilateral PAS was first attempted through a percutaneous single uterine access by internal rotation of the fetus, which was achieved by using the blunt tip of the same cannula, and in case of a failed procedure, a second uterine port was used to place the second shunt. The perinatal outcomes between successful (single uterine port) and failed (2 uterine ports) fetal procedures were compared. Results: Placing of bilateral shunts through a percutaneous single uterine access was feasible in 15/25 (60%) cases. Overall, median GA at delivery was 35.2 weeks with a survival rate of 64.0% (16/25). Three cases were excluded due to shunt dislodgement, leaving a final population of 22 fetuses; 13/22 (59.1%) and 9/22 (40.9%) managed using 1 and 2 uterine ports, respectively. The group with bilateral PAS placement through a successful single uterine port showed a significantly higher GA at birth (36.5 vs. 32.8 weeks, p = 0.001), lower surgical time (11.0 vs. 19.0 min, p = 0.01), longer interval between fetal intervention and delivery (5.7 vs. 2.7 weeks, p = 0.01), lower risk of preterm delivery (46.2 vs. 100%, p < 0.01), and lower rate of perinatal death (15.4 vs. 55.6%, p < 0.05) than the failed procedures requiring 2 uterine ports. Conclusion: In fetuses with severe bilateral hydrothorax and hydrops, bilateral pleuroamniotic shunting through a successful single percutaneous uterine access is feasible in up to 60% of cases and is associated with better perinatal outcomes.

Tracheoinnominate fistula due to high-riding innominate artery: A rare but potentially life-threatening complication following long-term tracheostomy

Tracheoinnominate fistula (TIF) is a rare but potentially life-threatening complication after tracheostomy. TIF was mostly observed within 7–21 days after tracheostomy but can present even years after tracheostomy. The risk factors for TIF are high cuff pressure, mucosal trauma from malpositioned cannula tip, low tracheal incision, excessive neck movement (hyperextension), radiotherapy, prolonged intubation, and high-riding innominate artery (HRIA). HRIA is also a rare anatomical variation of the innominate artery (IA) whereas IA bifurcates above the sternoclavicular joint. We report a rare case of TIF in a patient with HRIA, who presented with airway bleeding 2 months after percutaneous tracheostomy (PT) and was successfully managed with aggressive resuscitation and midline sternotomy. Knowledge of anatomical variation of the aortic arch and its major branches is essential for the physician who is routinely performing or managing tracheostomy. All the health-care workers involved in the management of tracheostomy should bear this complication in mind while dealing with any airway bleed. We recommend the routine use of bedside neck ultrasonography before all PTs to locate any aberrant vessel within the vicinity of tracheostoma to prevent this complication.

Unusual pattern of inferior vena cava thrombosis after veno-arterial extracorporeal membrane oxygenation: a report of two cases

We report two cases of inferior vena cava (IVC) thrombosis after the retrieval of veno-arterial extracorporeal membrane oxygenation cannulas. In both patients, the venous cannula tips were placed in the upper half of the right atrium, enabling adequate blood drainage. During support, uneventful periods of IVC collapse were detected. After decannulation, thrombotic formations resembling a mold of the venous cannula were detected in both patients. Whether the IVC collapse caused IVC thrombosis during VA-ECMO support remains to be determined in further trials.

In Vitro Evaluation of Flow Distribution in All-Region Perfusion during the Norwood Operation

Continuous all-region perfusion has the potential to reduce total body ischemia during the Norwood procedure. This technique involves placing cannulas in the innominate artery, descending aorta, and native aortic root, thus providing continuous flow to the whole body at mild hypothermia (32–34°C) during the entire operation. However, the cannulation strategy in this approach must be optimized to achieve adequate flow rates to all vascular beds. To ensure appropriate blood flow rates to three cannulas of different caliber supplied by two inflow pumps, a benchtop evaluation of comparative flow rates through branched cannulas with variable independent perfusion pressures was conducted. Two isolated vertical columns with outlets at 10 mmHg intervals to allow for adjustable perfusion pressures were filled with expired banked packed red blood cells and fresh frozen plasma. The main arterial line was bifurcated with an 8-Fr arterial cannula inserted at the base of one column and a 4-mm (outside diameter [OD]) olive tip cannula inserted at the base of the other column. Flow rates were measured on each branch of the ¼″ arterial lines. Under experimental cardiopulmonary bypass (CPB) perfusion pressures of 30–50 mmHg on the 8-Fr arterial cannula column, the branched olive tip cannula accommodated less than 25% of total flow at total flow rates of 50–700 mL/min. This fraction is insufficient to sustain adequate lower body perfusion. However, the olive tip flow fraction was found to be sufficient for coronary blood flow (5–20 mL/kg/min) when olive tip perfusion pressures close to average neonatal diastolic blood pressures (20–60 mmHg) were tested. For all-region perfusion during the Norwood operation, primary CPB arterial flow should be divided to the head and coronary circulation with an independent pump delivering flow to the descending aorta. This should avoid cerebral over-circulation and insufficient flow to the lower body.

Sustained Total All-Region (STAR) Perfusion: An Optimized Perfusion Strategy for Norwood Reconstruction.

Early iterations of the Norwood procedure used aortic cross-clamping, myocardial arrest, and, sometimes, deep hypothermic circulatory arrest. The resulting hypothermia and prolonged ischemia caused frequent cardiac, neurologic, renal, and other end-organ dysfunctions. Our group describes a novel technique, sustained total all-region (STAR) perfusion, which circumvents these issues by providing continuous perfusion to the head, heart, and coronaries at temperatures of 32-34°C. A single DLP® straight venous cannula (Medtronic, Minneapolis, MN) is placed in the right atrium, and a DLP® pediatric arterial cannula, with a high-flow stopcock attached, is placed in the ascending aorta or innominate artery to provide flow to the head. A cardioplegia needle with walrus tubing is connected to the stopcock to provide flow to the coronary arteries. For lower body perfusion, an olive tip cannula is placed into the descending aorta lumen and attached to the 1/8″ line from the cardioplegia system which provides warm arterial blood flow. STAR perfusion allows the Norwood procedure to be completed with mild hypothermia and continuous perfusion to all vascular beds with reduced cardiopulmonary bypass as well as total operative times. This technique is successfully achieved with minimal changes to circuitry, minor modifications to heart-lung machine servoregulation and few additional cannulation disposables.

Sustained Total All-Region (STAR) Perfusion: An Optimized Perfusion Strategy for Norwood Reconstruction

Early iterations of the Norwood procedure used aortic cross-clamping, myocardial arrest, and, sometimes, deep hypothermic circulatory arrest. The resulting hypothermia and prolonged ischemia caused frequent cardiac, neurologic, renal, and other end-organ dysfunctions. Our group describes a novel technique, sustained total all-region (STAR) perfusion, which circumvents these issues by providing continuous perfusion to the head, heart, and coronaries at temperatures of 32–34°C. A single DLP®straight venous cannula (Medtronic, Minneapolis, MN) is placed in the right atrium, and a DLP®pediatric arterial cannula, with a high-flow stopcock attached, is placed in the ascending aorta or innominate artery to provide flow to the head. A cardioplegia needle with walrus tubing is connected to the stopcock to provide flow to the coronary arteries. For lower body perfusion, an olive tip cannula is placed into the descending aorta lumen and attached to the 1/8″ line from the cardioplegia system which provides warm arterial blood flow. STAR perfusion allows the Norwood procedure to be completed with mild hypothermia and continuous perfusion to all vascular beds with reduced cardiopulmonary bypass as well as total operative times. This technique is successfully achieved with minimal changes to circuitry, minor modifications to heart–lung machine servoregulation and few additional cannulation disposables.