PU L S AT I L E

PE R F U S I O N
ANJANA V P
TI TUT E OF MEDI CAL
A.J.INS
ENCES, MAN GALORE
SCI
C.I.A.H.S,
BANGALORE
• PULSE-
:PRESSURE CHANGES TRANSMITTED IN THE FORMS OF WAVES THROUGH
THE ARTERIAL ELASTIC WALL AND BLOOD COLUMN FROM HEART TO PERIPHERY.
OR
PRESSURE WAVE PRODUCED IN THE ELASTIC WALL OF AORTA AND NOT
TRANMITTED TO CAPILLARIES.

EXISTENCE OF PULSATIONS IN CIRCULATION IS RECOGNISED FOR MANY

CENTURIES.
PULSATILITY
• IT IS AN INTRINSIC ASPECT OF HUMAN CARDIOVASCULAR SYSTEMS,AS
THE BEATING HEART GENERATES PERIODICALLY ALTERNATING BP AND
FLOW.

• THE NATIVE CIRCULATION PRODUCES PULSATILE FLOW, AND THE

PULSATILITY IS THOUGHT TO PROVIDE HEMODYNAMIC AND METABOLIC
BENEFIT.

• CAPILLARY PERFUSION IS FACILITATED BY THE INCREASED ENERGY

CONTAINED IN PULSATILE FLOW AND BY LONGER PERIODS OF
MICROCIRCULATORY PATENCY OCCURRING DURING PEAKS OF
PULSATILE SYSTOLIC PRESSURE.
• PREFERRED PERFUSION METHOD FOR CPB.
• THERE IS NO DOUBT THAT THE PULSATILE PUMP FUNCTIONOF
THE HEART OFFERS SIGNIFICANT PHYSIOLOGIC ADVANTAGES
OVER CONTINUOUS [NON-PULSATILE] FLOW BY PROVIDING
DIASTOLIC RUN OFF AND STIMULATION OF THE ENDOTHELIUM.

• CLINICAL EVIDENCE SHOW BETTER

CARDIAC,RENAL AND
PULMONARY OUTCOMES IN PATIENTS RECEIVING PULSATILE
PERFUSION

• HOWEVER ACHIEVING A PHYSIOLOGICPULSATILE FLOW FROM A

NON-COMPLIANT HIGH RESISTANCE CPB CIRCUIT IS DIFFICULT.
EFFECTS OF PULSATILE FLOW
•METABOLIC EFFECT
•HEMODYNAMIC EFFECT
•EFFECT ON BRAIN FUNCTION
•EFFECT ON KIDNEY FUNCTION
•EFFECT ON PANCREATIC AND LIVER FUNCTION.
A) METABOLIC EFFECTS
• REDUCED TISSUE OXYGEN CONSUMPTION.
• DECREASED PROGRESSIVE ACIDOSIS.
• REDUCED LACTATE ACCUMULATION.
NON-PULSATILE HAVE DETRIMENTAL EFFECT ON CELL METABOLISM
AND ORGAN FUNCTION.
NON-PULSATILE ASSOCIATED WITH DECREASED GLUCOSE UPTAKE AT
CELLULAR LEVEL.
PULSATILE PROVIDES METABOLIC ADVANTAGE OVER NON
PULSATILE.
 B] HEMODYNAMIC EFFECTS

• PULSATILE FLOW;- MORE CLOSELY RESEMBLES THE PATTERN OF

BLOODFLOW GENERATED BY THE CARDIAC CYCLE AND SHOULD
THEREFORE MORE CLOSELY EMULATE THE FLOW
CHARACTERISTICS OF THE PHYSIOLOGICAL CIRCULATION.
• ENHANCING FLOW THROUGH SMALLER CAPILLARY NETWORKS.
• DECREASED PVR-THUS PROMOTING IMPROVED PERFUSION,THIS
SUBSEQUENTLY INVOLVES LV FUNCTION.
C] EFFECT ON KIDNEY FUNCTION
• IMPROVED KIDNEY FUNCTION IS THE RESULT OF BETTER GAS
EXCHANGE AT THE CAPILLARY LEVEL TOGETHER WITH THE
MAINTENANCE OF NORMAL LYMPH FLOW.

• PULSATILE PERFUSION PRODUCES SIGNIFICANTLY LOWER PLASMA

LEVEL OF RENIN AND ANGIOTENSIN II.

• NON –PULSATILE FLOW INCREASES SECRETION OF RENIN.

• PULSATILE PERFUSION PRESERVES RENAL CORTICAL
BLOODFLOW,RENAL VENOUS RETURN AND RENAL TUBULAR
HISTOLOGY.
• RENAL VASCULAR AUTOREGULATION EXERTS A CONSIDERABLE
PROTECTIVE MECHANISM.THIS PROTECTS KIDNEY FROM
DELETERIOUS EFFECT OF ALTERED PERFUSION.
• KIDNEY IS MORE RESISTANT TO PERFUSION DIFFERENCE
B/W PULSATILE AND NON –PULSATILE FLOW.AR
D] EFFECT ON PANCREATIC AND
LIVER FUNCTION
• PRESERVES PANCREATIC FUNCTION BETTER THAN
NONPULSATILE CPB.
• "NORMAL FUNCTION" OF THE PANCREATIC -CELLS WITH
PULSATILE BLOOD FLOW .. REDUCED FUNCTION IN THE
NONPULSATILE FLOW IS OBSERVED.
• REDUCED INCIDENCE OF ELEVATED AMYLASE LEVELS IN
PATIENTS UNDERGOING CPB WITH PULSATILE FLOW.
• HEPATIC FUNCTION IS ALSO PRESERVED AS REFLECTED IN
POSTOPERATIVE SGOT LEVEL.

• HEPATIC BLOOD FLOW SHOWS A VASOCONSTRICTIVE

RESPONSE TO NONPULSATILE CPB WITH DECREASE IN HEPATIC
OXYGEN CONSUMPTION

• HEPATIC BLOODFLOW SHOWS TYPICAL VASOCONSTRICTION

AND REDUCTION IN HEPATIC OXYGEN CONSUMPTION TO NON-
PULSATILE FLOW.
E] EFFECT ON BRAIN FUNCTION
• PULSATILE FLOW PREVENTS THE CEREBRAL ACIDOSIS OFTEN OBSERVED DURING
THE EARLY PHASE OF NON-PULSATILE CPB. THIS MAY BE DUE TO BETTER
PRESERVATION OF REGIONAL CEREBRAL BLOOD FLOW.

• PULSATILE FLOW REDUCES CEREBRAL VASCULAR RESISTANCE BY AS MUCH AS

25%.

• THE IMPROVEMENT IN REGIONAL BLOOD FLOW DISTRIBUTION CAUSES REDUCED

CEREBRAL LACTATE PRODUCTION .

• ANAEROBIC METABOLISM IS SUPPRESSED WITH PULSATILE BLOOD FLOW,

PARTICULARLY DURING THE CRITICAL COOLING AND REWARMING PHASES.
• STUDIES HAVE DEMONSTRATED SIGNIFICANT REDUCTION IN
CEREBRAL ARTERIOLAR AND CAPILLARY DIAMETER DURING
NON- PULSATILE FLOW.

• CEREBRAL BLOOD FLOW IS NOT DISTRIBUTED UNIFORMLY AND

CERTAIN AREAS MAY REQUIRE HIGH BLOODFLOW AND THUS
BECOME COMPROMISED, IF AUTOREGULATION FAILS.

• ANTERIOR PITUITARY SECRETION OF ACTH FALLS DURING NON

–PULSATILE FLOW.
THEORIES OF PULSATILE
PERFUSION
1. CONCEPT OF ENERGY EQUIVALENT FLOW.

2. CAPILLARY CRITICAL CLOSING PRESSURE& MICROCIRCULATORY

PATENCY.

3. NEURO ENDOCRINE REFLEX MECHANISM ,TRIGGERED BY

BARORECEPTOR DISCHARGE.
 CONCEPT OF ENERGY EQUIVALENT PRESSURE.
• PRODUCTION OF PULSATIE FLOW DEPENDS NOT ON A PRESSURE
GRADIENT BUT ON AN ENERGY GRADIENT.

• IT WAS MATHEMATICALLY DEMONSTRATED THAT , “PULSATILE FLOW

REQUIRED 2-3 TIMES MORE ENERGY THAN NON-PULSATILE
FLOW”

• THE EXTRA ENERGY WAS THOUGHT TO BE AVAILABLE FOR THE

TISSUES.

• THIS ENERGY HELP IN THE MAINTANANCE OF CAPILLARY PATENCY&

TISSUE LYMPH FLOW.
• OSCILLATORY MOVEMENT AT CELL-LEVEL ,WHICH IMPROVES
CELLULAR METABOLISM.

• CONTRAVERSY WITH PULSATILE FLOW:-

i. LACK OF TECHNOLOGICALLY SATISFYING PUMP SYSTEM
ii. LACK OF QUALIFICATION OF ARTERIAL PROMD PUMP WAVE
FORM.
CAPILLARY CRITICAL CLOSING PRESSURE
AND MICROCIRCULATORY PATENCY
• THE BELIEF THAT WHEN THE PRESSURE IN THE CAPILLARIES GOES BELOW A
CERTAIN POINT,THE CAPILLARIES WILL CLOSE.-THIS WILL REUCES THE GAS
EXCHANGE FROM BLOOD TO TISSUES.

• STUDIES SUGGESTS THAT THERE IS REDUCED CAPILLARY PERFUSION AND

REDUCED CEREBRAL CAPILLARY DIAMETER ASSOCIATED WITH NPF.

• PULSATILE FLOW ENSURESAN EFFECTIVELY GREATER PERIOD OF

MICROCIRCULATORY PATENCY.

• WITH NON-PULSATILE FLOW,REDUCED MICROCIRCULATORY PATENCYOR MORE

CAPILLARY SHUNTING [REDUCED CAPILLARY PERFUSION] AND CAPILLARY
COLLAPSE TAKES PLACE.

• THIS RESULTS REDUCED OXYGEN CONSUMPTION AND FINALLY TISSUE ACIDOSIS.

 NEURO ENDOCRINE REFLEX
MECHANISM

• BARORECEPTOR RESPOND TO BOTH STATIC AND PULSATILE ASPECTS OF

WAVEFORM.

• THE BARORECEPTOR MECHANISM OF NON-PULSATILE FLOW CAUSES

INCREASE IN CAROTID SINUS BARORECEPTOR DISCHARGE FREQUENCY
CAUSING REFLEX VASOCONSTRICTION IN THE PERIPHERAL CIRCULATION.
• NON –PULSATILITY-
DECREASED CAPILLARY PERFUSION
INCREASED MICROCIRCULATORY SHUNTING
ALTERS CELL MECHANISMS [ METABOLISM ]
REDUCED OXYGEN CONSUMPTION.
 BENEFITS OF PF
1.INCREASE BLOOD FLOW IN MICROCIRCULATION.
2.FACILITATE AEROBIC METABOLISM DUE TO INCREASE
MICROCIRCULATION.
3.DECREASE RELEASE OF BARORECEPTOR REFLEX HORMONES,
LIMITING VASOCONSTRICTION.
4.INCREASES RENAL, CEREBRAL, PANCREATIC FLOW.
5.ATTENUATION OF THE SYSTEMIC INFLAMMATORY RESPONSE
DURING CPB.
6.ATTENUATION OF HORMONAL RESPONSES : CATACOLAMINES,
RENIN ANGIOTENSIN ALDOSTERONE, ANTIDIURETIC HORMONE,
CORTISOL, THROMBOXANE, PROSTACYCLIN.
7.INCREASE IN LYMPHATIC FUNCTION.
8.INCREASE CAPILLARY PERFUSION.
9.REDUCED MARKERS OF ENDOTHELIAL DAMAGE.
10.DECREASED NEED FOR INOTROPIC SUPPORT, SHORTENED
HOSPITAL STAY, AND SUPERIOR ORGAN PRESERVATION
 PULSATILE PERFUSION SYSTEMS

• MODIFIED ROLLER PUMP

• DIAGONAL PUMPS
• GENERATION OF PULSE USING I A B P
• CFP / IMPELLER PUMPS
• VENTRICULAR PUMPS

MODIFIED ROLLER PUMP SYSTEM -INCORPORATE A PUMP HEAD WHICH

ACCELERATES IN SYSTOLIC PHASE GENERATING PULSE AND DECELERATES DURING
DIASTOLE.
• ADVANTAGES:-
 SIMPLE
 RELIABLE
 MANUALLY OPERATABLE
 ALLOWS TO INCORPORATE PULSATILE SYSTEM INTO THE
EXISTING CIRCUIT AND CANNULA.
ALL NECESSARY CONTROLS ARE PRESENT ON PUMP FACE .
NOT ASSOCIATED WITH SIGNIFICANT HEMOLYSIS.
IS ROLLER PUMP REALLY GENERATES
PULSATILE FLOW?

• IT GENERATES A RIPPLE FLOW.

• IT IS NOT CAPABLE OF MATCHING THE HYDRAULIC POWER OUTPUT OF THE
HUMAN HEART.

• BUT THERE IS CLINICAL EVIDENCE THAT THOUGH THE PULSE IS LESS

OPTIMAL THERE ARE BENEFITS.
CFP
•“EEP” [ENERGY EQUIVALENT PRESSURE]AND
“SHE”[SURPLUS HEMODYNAMIC ENERGY] ARE
MINIMUM.
•HEAT GENERATION IS MORE.
•AFTERLOAD DEPENDANCE ,MAKE THEM UNRELIABLE
FOR THIS PURPOSE.
 PULSE GENERATION IN IABP
• IT IS AN INTERMITTENT OCCLUSIVE DEVICE
THAT EMPLOYS AN IAB TO
PRODUCE AN PULSATILE FLOW IN ARTERIAL LINE OF CPB CIRCUIT.
• ON DEFLATION OF THE BALLOON IN THE ARTERIAL LINE, THE
PRESSURE AND VOLUME ARE RELEASED IN THE AORTA TO THE
PATIENT AS A PULSE.

CONCERNS WITH THIS DEVICE ARE

• IT INCREASES THE COMPLEXITY OF THE CIRCUIT
• FEAR OF BALLOON RUPTURE IN THE ARTERIAL LINE
• HEMOLYSIS
• GASEOUS MICROEMBOLI MAY FORM.
 VENTRICULAR PUMPS/VAD
• THE MOST USED PHYSIOLOGIC METHOD FOR GENERATING PULSATILE BLOOD
FLOW, IN THAT THEY OPERATE IN SIMILAR MANNER TO THE VENTRICLE OF
THE HEART.

• IN SIMPLE TERMS, VENTRICULAR SYSTEMS CONSIST OF COMPRESSIBLE SAC

AND TWO ONE-WAY VALVES PERMITTING BLOOD TO FLOW INTO AND OUT OF
THE VENTRICLE IN ONLY ONE DIRECTION.
COMPATIBILITY OF PULSATILE PERFUSION WITH CIRCUIT COMPONENTS

• THE ECC PRESENTS AN ENTIRELY DIFFERENT HEMODYNAMIC ENVIRONMENT

THAN THE NATIVE CIRCULATORY SYSTEM.

• THREE DEVICES BTW PT AND PUMP [ OXY.,FILTER AND AORTIC CANNULA ]CAN
REDUCE THE PULSATILITY.[P-DROP]

• TUBINGS CAN ALSO EXHIBIT ENERGY ADSORPTION CAPABILITY.

• TUBING SHOULD BE SHORT AND RIGID WITH MIN.CONNECTORS.
• FOR EFFECTIVE PULSATILITY AO.CANNULA SHOULD BE AS BIG AS THE
TUBE.BUT THIS IS PRACTICALLY DIFFICULT.
• IT IS IMPORTANT TO SELECT SATISFACTORY CIRCUIT COMPONENTS SO THAT
ENERGY LOSS IS MINIMIZED.

• OBSTACLES-
LENGTH OF TUBING
RESISTANCE AND DAMPING OF THE CANNULAE[SMALL SIZE WILL LEAD
TOCIRCUIT DSTRESS AND HEMOLYSIS],OXYGENATOR,ALF ETC
 COMPARISON
PULSATILE FLOW NON –PULSATILE

FLOOW
2-3 TIMES MORE ENERGY LOWER ENERGY

MICROCIRCULATORY SHUNTING INCREASED MICROCIRCULATORY

PREVENTED SHUNTING
REDUCED RENIN-ANGIOTENSIN SYSTEM INCREASED RENIN-ANGIOTENSIN SYSTEM
ACTION ACTION
CAPILLARY PATENCY MAINTAINED CLOSING OF CAPILLARIES OCCUR

METABOLISM PRESERVED REDUCED METABOLISM

No acidosis Causes acidosis
Maintain oxygen consumption Reduced oxygen consumption
Increased capillary perfusion Decreased capillary perfusion
Hemodynamic and metabolic benefits Detrimental effects on cell metabolism and
organ functions
Integrity of vascular compartment is better Reduced glucose uptake at cellular level
maintained
Mimics natural flow pattern and flow Doesn’t mimics it
characteristics of physiologic circulation

Decreased peripheral vascular resistance. Increased peripheral vascular resistance.

Brain:-
• Cerebral cellular integrity is better • Reduction in anti-pituitary secretion of
maintained. ACTH.
• Increased cerebral bloodflow. • Reduction in cerebral arteriolar
&capillary diameter.

Kidney:-
• Reduced renin-angiotensin II levels. Increased renal secretion of renin.
• Preserves renal cortical blood
flow,renal venous return and renal
tubular histology.
Pancreas:
lower level of serum amylase
Lower incidence of elevated amylase
creatinine clearance ratio.
Liver:
Maintains hepatic arterial bloodflow & Hepatic bloodflow &O2 consumption reduces
metabolism to 50% of thenormal value.
Heart:
• Useful in both long and short term Increase in afterload &ventricular
circulatory devices. work ,because of increment in SVR due to
• Increases myocardial bloodflow. RAS activation.
• Increase in aortic pressure and cardiac
output.
• Prevents increase in afterload &
ventricular work .
Blood:
• Increased hemolysis.
• Improves hemodynamics.
• Decreased requirement of inotropic
drugs and IABP support.
THANK YOU