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ZappaBaggins43 karma

I'm a cardiovascular perfusionist, the person who would run the heart/lung machine during your surgery. It isn't uncommon for other health care professionals to not know who we are or what we do (as of 2018, there are somewhere around 3,800 of us in the entire U.S.). So I always wonder if our patients know we exist or what we do. So all of that said, did your surgeon describe the heart/lung machine to you or the role of the perfusionist? I'm just curious. I kind of like the anonymity of my job.

ZappaBaggins16 karma

I haven't read it, but will look into it. Thanks for the recommendation! Btw, your family and those like you are why I got into my current profession. I was a PICU nurse before I became a perfusionist and hearts were my favorite patients (and cancer patients, because those kids are inspiring). So thank you to your son and yourself for your struggles and bravery.

So the gist of why people in my profession are necessary for most heart surgery is that for most cases the surgeon needs a bloodless and motionless field to operate. To achieve this we must drain the heart of blood and arrest it so that it is not beating. So this is how it is typically done:

A cannula is placed in the right atrium (sometimes two cannulas, depending on the operation) and connected to a length of tubing we call the venous line. This cannula drains the blood as it enters the right atrium. Then the blood goes down the venous line into a reservoir.

From the reservoir it goes to a pump (there are two types of pumps, but I won't go there now). The pump drives the blood forward and gives it enough pressure to provide the patient with adequate perfusion. Think of this as the heart of the heart/lung machine.

The blood is pumped into an oxygenator, which oxygenates the blood and removes CO2. This is the lung of the machine. From the oxygenator there is one length of tubing that goes to a separate pump we call the cardioplegia pump, I'll talk about that later. Another, larger length of tubing called the arterial line exits the oxygenator and is connected to a cannula that is placed in the aorta.

For most cases the surgeon will arrest the heart. This is accomplished through the delivery of cardioplegia, a solution that typically is high in potassium and mixed with arterial blood from the outlet of the oxygenator. This solution is also usually delivered ice cold. Delivery is accomplished by forcing this solution into the coronary arteries where they exit the aorta just above the aortic valve. To do this, the surgeon places a clamp across the aorta above the coronary Ostia (where the coronary arteries come off of the aorta). Below this a needle is placed in which the cardioplegia solution is delivered. It travels down the arteries into the heart tissues and arrests the heart. While not beating, the surgeon can better perform his job and the heart in its cold and motionless state consumes less energy and is thus not damaged by temporary lack of blood supply.

The surgeon then performs whatever procedures are required while the perfusionist keeps the body supplied with oxygenated blood. When the procedure is done, the surgeon takes the clamp off of the aorta, the heart "wakes up", and we come off bypass. It's all much more complex than this, but also not completely as complex as it probably sounds. If that makes any sense at all... I probably left a lot out, some intentionally and some unintentionally.

ZappaBaggins5 karma

In the U.S. it's typically a Masters or post-graduate degree. There something like 17 schools across the nation. I believe perfusion.com has a complete list of the programs. There are a few in the northeast, one in South Carolina, one in Chicago, one in Houston, and I think two in Arizona. It's fairly competitive. The job market for perfusionists is very strong right now. In most places you'll start out at or very near to six figures.

Edit: sorry I forgot to mention certification. Certification is accomplished by qualifying to take the board exams by completing and accredited perfusion program, pumping 75 cases in school, and 40 cases after you graduate. Many states have state licensure in addition to national certification.

ZappaBaggins4 karma

Ha! Thanks, but we're all just regular people living our lives out here like everybody else out there. I do appreciate your appreciation though!

ZappaBaggins3 karma

So that would likely be what we call an OPCAB (off pump coronary artery bypass). Typically this is done for low risk patients that don't need more than a vessel or two bypassed. In my experience they use a suction device to hold the heart in place while the surgeon is doing his grafts. Not all cardiothoracic surgeons do off pump procedures though.

Another procedure in which the heart isn't typically arrested is VAD (ventricular assist device) placement. These cases however, are on pump procedures.