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EDICAL
JOURNAL
Foreword
Some years ago the department of surgery in the Postgraduate Medical School of London was concerned with
research in the perfusion of isolated human organs. The
perfusion of isolated organs by blood artificially oxygenated and propelled by a mechanical pump cannot
be continued for more than a few hours. After some
hours the perfused organ swells visibly and the outflow
of blood from it progressively and rapidly diminishes.
After a short and not very successful examination of the
problem of prolongation of the survival time of isolated
organs in these conditions attention was turned to the
extracorporeal heart-lung circulation for the maintenance of the circulation of the experimental animal
by a total replacement of its own heart and lungs, comparable to that which would be required in the application of an apparatus of this kind to intracardiac
surgery. It seemed to us, after some experience in this
field, that a machine to undertake the whole function
of heart and lungs in a patient subjected to intracardiac surgery was not yet an immediately attainable
aim.
Animals maintained entirely on an extracorporeal heartlung circulation sometimes survive for indefinite periods,
but a high proportion fail to survive, perhaps for reasons
not dissimilar to those which make prolonged perfusion
of the isolated organ impossible. The natural lung may
have other functions than oxygenation. In any case,
there are immediate practical difficulties in employing a
heart-lung machine to replace the heart and lungs of a
patient subjected to cardiac surgery. Heparinization
must be complete, and the difficulty of obtaining a bloodless field even in a heart to which blood is not returned
,by the venae cavae has already been demonstrated at
least once in man. Our attention accordingly passed
to the use of a heart-lung machine as a form of " assisted
circulation."
Our aim in this field became the ultimate use of an
artificial heart-lung machine for the treatment of certain
acute forms of cardiac or pulmonary failure. The value
of artificial oxygenation of the blood for even a short
period in acute pulmonary oedema or status asthmaticus
seemed obvious enough, for, provided the patient can be
kept oxygenated for a time, these pathological circumstances are often self-limiting. In coronary thrombosis
there are patients in whom it might be expected that the
*Part of the work was done under the tenure of a Studentship
in Research from the Medical Research Council.
The Pump-oxygenator
BRITISH
MEDICAL JOURNAL
apparatus should be capable of being completely dismantled for effective cleaning. (6) Adequate surface
area should be, obtained without the use of a very large
volume of blood to charge the machine. (7) For ease
in maintaining sterility, a system as nearly closed as
possible is desirable.
From these considerations it is seen that enlarging the
diameter of the disks makes a longer exposure of time
inevitable if a safe rotational speed is to be maintained,
while increasing the number of disks greatly increases
the blood volume required for charging. Neither of
these measures, nor a combination of them, confers any
improvement in the mixing, or in ensuring the maintenance of an optimum blood film size.
The Oxygenator
The new oxygenator (Fig. 2) is essentially a rotating
cylinder set at a slight angle to the horizontal. Within it
blood travels under the influence of gravity from one end
to the other, and is spread over a multitude of surfaces
formed by blades projecting into the lumen of the cylinder.
These blades are arranged within the cylinder somewhat in
the form of an Archimedean helix. This analogy is not
strictly accurate, but may clarify the method of construction,
which is in fact carried out in the following manner. A
cylinder of " perspex " 30 in. (76 cm.) in length and of
internal diameter of 8 in. (20.3 cm.) is free to rotate in its
long axis while supported on rollers at 20 degrees to the
horizontal. It is closed at each end by an end-plate of
" tufnol " 10 in. (25.4 cm.) in diameter. In this cylinder
They are constructed from perspex 5/16 in. (0.8 cm.) thick.
The holes in the plates are concentric, but the holes in the
washers are cut eccentrically, the centres of the hole being
1 in. (2.54 cm.) from the true centre of the washers.
These plates and washers are mounted in the cylinder
on chromium-plated rods and are freely detachable for
cleaning. A maximum of 76 plates and their separating
washers may be used to provide a surface area of approximately 1 square metre.
The plates (Fig. 3) are fitted so that their central holes
form a cylindrical cavity, coaxial with the enclosing cvlin-
oxygenator
in sagittal section.
as
by 1 in. (2.54 cm.) than that of the plates, these plates project as crescents within the cavity formed by the holes in
the washers. Each group of five washers and plates is
arranged relative to the next group so that crescentic protrusions of the plates are at opposite poles. In sagittal
section, therefore, the cylinder presents a series of alternating
platforms and troughs, these troughs being subdivided into
five compartments by the five plates (Fig. 4).
Passage of the Blood
In describing the path of the blood passing by gravity
along the tilted oxygenator, it is helpful to consider first
the hypothetical case in which both washers and plates
are fitted so that the holes in them are concentric.
A
pool of blood would lie along the base of the cylinder
formed by the holes in the washers to the depth of the
level of the holes in the plates. Rotation of the oxygenator
would not affect the position of the pool in space. Where
the holes in the washers are eccentric to the holes in the
plates and the circumferences of these holes touch at one
point in any group of five, a different action is apparent.
When the point of touching is at top centre a pool of blood
will be formed as in the previous case. During any revolution, as the point of touching approaches bottom centre this
pool will be emptied by the action of the washers, which
in effect rise to the level of the holes in the plates. The
alternation of phase between adjacent groups ensures that
as a pool in one group empties so it is re-created in the next
group.
BRTImSH
MEDICAL JOURNAL
59
60 JULY
11, 1953
BRnSH
MEDICAL JOURNAL
puts,
should
controlled
be
from
the
of
signal
from
imbalance
any
be-
the
volume
indicator
...7
same
flow.
The
FIG. 5
FIG. 6
FIG. 5.-One of the pumps unassembled, with the roller in a coIncentric position within the
circular housing. FIG. 6.-The roller moved to a fully eccentric position.
speeds
signal
derived
from
the
the
limit.
tion
pressure
rising
venous
above
of circula-
depends
on
the
as any
play
an
controlling system.
The signal
from the venous suction manometer performs the same function
in the control of the venous pump
as the arterial pressure signal does
nIG. I
FIG. 8
for the arterial pump-that is, it
tends to reduce the speed of pumpFIG. 7.-A loop of tubing in position between the pump housing and the roller, which is i
the concentric position. FfG. 8.-The pump fully assembled. T he tube is clamped within ing as the suction pressure rises,
the pump housing and is compressed by the roller, which has be(en adjusted to a degree of and will bring the circulation to
eccentricity sufficient to close the lumen of thie tube.
a stop when a limit is reached.
Hence a compromise is established
inner wall of the pump housing, causing it to squeeze the -the two pumps working to maintain the blood volume
tube in such a manner that a pumping action is obtained. and the arterial pressure, and to prevent the venous suction
Adjustment is simple and rapid, no blood comes into direct becoming too great.
contact with any moving parts, and a pulsatile flow is
This control gear, with its indicating instruments, warning
obtained.
lights, and switches, is housed in a separate trolley. On
the control panel of this trolley are arranged the manual
Control Mechanism
automatic speed-control selectors with meters indicating
The stroke volume depends only on the bore of the tube, and
the rate and pressure at which each pump is working.
and in the pump used this may be varied from * to + in. Another
meter indicates the volume of fluid in the oxygen(0.3 to 1.3 cm.) Both pumps are driven by fractional horse- ator. Warning
lights are placed above the pressure gauges
power D.C. shunt wound motors through reduction gearing
and the fluid volume meter to draw attention to any
and belt drive. These motors are of special type and are variations
that exceed chosen limits.
so designed that their speed may be controlled over a
10: 1 range by magnetic amplifiers (English Electric I h.p.
Working of the Pump-oxygenator
" magamp ").
These amplifiers have no thermionic valves
in them and are almost mechanical in operation, gaining
On the main trolley the pumps and oxygenator are
thereby in reliability and stability. They can be controlled arranged so that easy access to them is possible. The
by hand, and such adjustment will enable the circulation to oxygenator lies on rollers in a recess in the top of the
be operated under direct control. However, a rather more trolley and is covered by a transparent hood. Within this
sensitive control is achieved by an electronic apparatus recess a constant temperature can be maintained by warm
designed to replace the delicate balancing mechanism of the air, heated by infra-red lamps and circulated by a fan under
animal. This control gear takes as its guide three quanti- thermostatic control. Oxygen and carbon dioxide are
ties measured continuously by electrical manometers. These delivered to the oxygenator through rotameters which allow
are of the differential-transformer type and are particularly
adjustments of flow rate to maintain the appropriate carbon
stable. One measures the volume of blood in the artificial dioxide tension. The gases pass through a warming, filtercircuit from the depth of blood in the collecting chamber ing, and humidifying system and then traverse the oxygenof the oxygenator, one measures the pressure at which the ator in the opposite direction to that of the blood. A device
4'
operation.
When stored blood was used it was possible to introduce
approximately 100 volumes of oxygen into each litre of
blood flowing through it. At 2 litres a minute an average
figure is 205 c.cm. of oxygen uptake into stored blood. With
BDICJURNAL 61
BRf
=Jot_
EXPERIMENTAL PHYSIOLOGY OF A
HEART-LUNG MACHINE IN PARALLEL
WITH NORMAL CIRCULATION*
BY
'
oxygen consump30
0
60
tion, and the
MINUTES
electrocardiogra ph, which FIG. 1.-Red-cell count, haematocrit, and
w e r e then re-
corded
con-
in after
10 dogs
haemoglobin
plasma and
hour's
one before,
immediately
during,
perfusion.