Ultrafiltration and modified ultrafiltration in pediatric open heart operations.

The capillary leak associated with cardiopulmonary bypass results in an increase in content of water in the tissues measurable by an increase in total body water after cardiac operation. Following work by Magilligan in the 1970s, ultrafiltration was introduced during bypass as a means of hemoconcentrating patients and potentially removing water from the tissues. Conventional methods proved inconsistent; thus, we modified the technique to ultrafilter the patients immediately after cessation of bypass. Modified ultrafiltration takes 10 minutes and results in an elevation of the on-bypass hematocrit to about 35% or 40%. In pilot studies comparing bypass in absence of ultrafiltration with conventional ultrafiltration and modified ultrafiltration, only the modified technique was seen reliably to reduce the elevation in total body water to only 4%, within a narrow range. Subsequent prospective studies confirmed the reduction in accumulation of total body water and also demonstrated a reduction in blood loss and in requirements for blood transfusion. Systolic blood pressure was observed to increase uniformly in all patients undergoing modified ultrafiltration. This effect was investigated and found to be associated with a marked increase in cardiac index, no change in systemic vascular resistance, a decrease in heart rate, and a marked decrease in pulmonary vascular resistance. Recently, we have demonstrated an increase in contractility and a decrease in myocardial wall volume. The modified technique of ultrafiltration has been employed successfully in more than 400 patients in our institution, and represents an excellent option for perioperative management of both accumulation of fluid in the tissues and hemodynamics after hypothermic bypass.