The Impact of Miniaturized Extracorporeal Circulation on Thrombin Generation and Postoperative Blood Loss
Phase: NA
Conditions: Coronary Artery Disease
Sponsor: Aarhus University Hospital Skejby

Protocol  
Final Version  
01.09.2017
 
                                                           
1 
 
 
The impact of miniaturized extracorporeal 
circulation on thrombin generation and 
postoperative blood loss 
 
A randomized controlled clinical trial  
 
 
Principal Investigator (PI): 
Ivy Susanne Modrau, MD, dr.med sc. (german) 
Consultant Cardiac Surgeon, Associate Professor 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital, Denmark 
e-mail: ivy.modrau@skejby.rm.dk 
 
Supported by: 
NIH/NCRR Colorado CTSI Grant Number UL1 RR025780 (REDCap) 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
2 
 
TABLE OF CONTENTS 
Page 
 
ABBREVIATIONS 
4 
SYNOPSIS 
5 
Study title 
5 
Objectives 
5 
Design and outcomes 
5 
Intervention and Duration 
6 
Sample size and population 
6 
STUDY TEAM ROASTER 
7 
Principle Investigator 
7 
Co-investigators 
7 
PARTICIPATING STUDY SITES 
8 
1 
HYPOTHESIS AND STUDY OBJECTIVES 
9 
1.1. 
Hypothesis 
9 
1.2.  
Primary Objective 
9 
1.3.  
Secondary Objectives 
9 
2.  
BACKGROUND AND RATIONALE 
10 
1.1. 
Background 
10 
1.2.  
Rationale 
11 
3 
STUDY DESIGN AND OUTCOMES 
12 
3.1. 
Study Design 
12 
3.2. 
Primary Outcome Measure 
12 
3.3. 
Secondary Outcome Measures 
12 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS 
13 
4.1. 
Inclusion Criteria 
13 
4.2. 
Exclusion Criteria 
13 
4.3. 
Study Enrollment Procedures and Informed Consent 
14 
4.4. 
Study Duration and Follow-up 
15 
5. 
MATERIALS AND METHODS 
15 
5.1. 
Study treatment 
15 
5.2. 
Laboratory measurements 
17 

Protocol  
Final Version  
01.09.2017
 
                                                           
3 
 
6 
STUDY EVALUATIONS 
20 
6.1 
Description of Evaluations  
20 
6.2 
Schedule of Evaluations 
22 
7.  
SAFETY ASPECTS 
23 
7.1. 
Insurance 
23 
7.2.  
Adverse Events and Serious Adverse Events 
23 
7.3.  
Reporting procedures and follow-up 
24 
8.  
STATISTICS CONSIDERATIONS 
24 
8.1. 
General Design Issues  
24 
8.2. 
Sample Size and Randomization 
25 
8.3.  
Stopping rules 
25 
8.4. 
Data Analyses 
25 
9 
DATA COLLECTION AND QUALITY ASSURANCE 
26 
9.1. 
Data Collection Forms 
26 
9.2 
Data Management 
26 
9.3. 
Training 
26 
9.4. 
Protocol Deviations 
27 
10 
ECONOMY 
27 
11 
ETHICAL CONSIDERATIONS 
27 
11.1.  Risk of study intervention 
27 
11.2.  Conflict of interest 
28 
11.3. Approval 
28 
12  
STUDY ORGANIZATION 
28 
12.1 
Steering Committee 
28 
12.2 
Delegation of Study-related tasks 
28 
13  
COOPERATION AND PUBLICATION POLICY 
30 
14 
PLANNED TIMELINE 
31 
15  
PERSPECTIVES 
31  
16 
REFERENCES 
32 

Protocol  
Final Version  
01.09.2017
 
                                                           
4 
 
ABBREVIATIONS 
aPTT  
= activated partial thromboplastin times 
CABG  
= Coronary Artery Bypass Grafting 
CAT  
= Calibrated Automated Thrombography () 
cECC  
= conventional ExtraCorporeal Circulation 
CK-MB  
= Creatine Kinase-MB 
CRF 
= Case Report File 
CRP 
= C-Reactive Protein 
ECC 
= ExtraCorporeal Circulation  
ECG  
= ElectroCardioGram 
F 1+2 
= Prothrombin fragment 1+2 
GCP  
= Good Clinical Practice 
IL-panel 
= Interleukin panel                                                               
INR 
= International Normalized Ratio 
miECC  
= miniaturized ExtraCorporeal Circulation 
PI 
= Principle investigator 
PT  
= Prothrombin  
RCT 
= Randomized Controlled Trial 
SvO2 
= Mixed venous oxygen saturation 
TMF 
= Trial Monitoring File 
TNF-α 
= Tumor Necrosis Factor alpha 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
5 
 
SYNOPSIS 
 
Study Title 
The impact of miniaturized extracorporeal circulation 
on thrombin generation and postoperative blood loss - 
A randomized controlled clinical trial  
Primary Study Objectives 
To assess the impact of miECC compared to cECC on 
thrombin generation after CABG 
Secondary Study Objectives 
To evaluate the impact of miECC versus cECC on: 
 Blood loss and transfusion requirement  
 Coagulation and fbrinolysis 
 Inflammatory response 
 Haemodilution and haemolysis 
 Endorgan  protection 
 Feasibility and safety 
Study Design 
A single-center, double-blind, parallel-group 
randomized controlled trial 
Primary outcome measures 
 Postoperative thrombin generation 
Secondary  outcome measures 
Effects on: 
 Postoperative blood loss and transfusion 
requirement  
 Fibrinolysis: 
- Clot lysis 
- Fibrin D-dimer 
 Coagulation tests 
- Platelet count 
- aPTT, INR 
- Antithrombin 
- Fibrinogen  
- Prothrombin fragment 1+2 
 Inflammatory response  
- TNF-α, Interleukin panel 
- CRP, white blood count 
 Haemodilution (Nadir intraoperative haematocrit) 

Protocol  
Final Version  
01.09.2017
 
                                                           
6 
 
 Haemolysis (LDH) 
 End-organ protection : 
- Postoperative CK-MB for myocardial injury 
- Postoperative creatinine clearance for renal injury  
- Intraoperative blood lactate for inadequate tissue 
perfusion 
 Efficacy/safety and feasibility parameters  
- Perioperative myocardial infarction 
- In-hospital neurological events (TCI/stroke) 
- Postoperative requirement of renal replacement 
therapy 
- Re-exploration because of bleeding 
- Repeat revascularization 
- Length of ICU stay 
- Duration of inotropic support and mechanical 
ventilation 
- Incidence of atrial fibrillation in-hospital 
- Incidence of infection (requiring antibiotic 
therapy, wound revision for graft leg infection, 
superficial or deep sternal wound infection)  
- Feasibility of miECC as measured by conversion 
to cECC and intraoperative complications  
- 30-day MACCE (Death, MI, cerebrovascular 
accident, repeat revascularization, deep sternal 
wound infection) 
Study Intervention 
Non-emergent CABG with 
(1) miECC 
(2) cECC 
Duration 
Planned enrollment period:  09/2017 - 09/2018 
Data analysis:                       10/2018 - 02/2019 
Sample Size 
 
60 Patients undergoing CABG are randomized 1:1 to 
receive either miECC or cECC.  
Study Population 
Elective primary CABG  patients with ECC 

Protocol  
Final Version  
01.09.2017
 
                                                           
7 
 
STUDY TEAM ROSTER 
 
Principal Investigator: 
Ivy Susanne Modrau, MD 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark 
Telephone: +45 24778856 
E-Mail: ivy.modrau@skejby.rm.dk 
 
Co-Investigators: 
Debbie Richards Halle, perfusionist aspirant  
 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
 
E-Mail: debohall@rm.dk 
 
 
Anne-Mette Hvas, MD, PhD 
 
Department of Clinical Biochemistry 
Aarhus University Hospital 
 
E-Mail: annehvas@rm.dk 
 
 
Karsten Lund Søberg, Perfusionist 
 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
 
E-Mail: karstensoeberg@yahoo.com 
 
 
Peter Fast Nielsen, Perfusionist 
 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
 
E-Mail: petniels@rm.dk 
 
 
 
Per Hostrup Nielsen, MD 
 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
 
E-Mail: per.hostrup@skejby.rm.dk 
 
 
 
 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
8 
 
 
Hans Henrik Kimose, MD 
 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
E-Mail: hans.h.kimose@skejby.rm.dk 
 
 
 
Sandeep Prataprao Tambe, MD 
 
Department of Anaesthesiology and Intensive Care 
Aarhus University Hospital 
 
E-Mail: sandtamb@rm.dk 
 
 
 
Pia Katarina Ryhammer, MD 
 
Department of Anaesthesiology and Intensive Care 
Aarhus University Hospital 
 
E-Mail: piaryham@rm.dk 
 
 
Jacob Raben Greisen, MD 
 
Department of Anaesthesiology and Intensive Care 
Aarhus University Hospital 
 
E-Mail: jacogrei@rm.dk 
 
 
 
 
PARTICIPATING STUDY SITES 
 
Department of Cardiothoracic and Vascular Surgery 
Aarhus University Hospital 
Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark 
 
Department of Clinical Biochemistry 
Aarhus University Hospital 
Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark 
 
Department of Anaesthesiology and Intensive Care 
Aarhus University Hospital 
Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
9 
 
1.  
HYPOTHESIS AND STUDY OBJECTIVES 
 
 
1.1. Hypothesis 
We propose that miniaturized extracorporeal circulation (miECC) is associated with higher 
thrombin generation as an indicator of preserved haemostatic capacity early after coronary 
artery bypass grafting (CABG) compared to conventional extracorporeal circulation (cECC). 
We hypothesize that the preserved haemostatic capacity will be associated with reduced 
postoperative bleeding. 
 
1.2. Primary objective 
The primary objective of this study is to investigate whether the use of miECC will result in 
preserved overall haemostatic capacity early after CABG as measured by thrombin generation 
potential compared with the use of cECC.  
 
1.3.  Secondary objectives 
 
The secondary objectives of this study are to compare miECC with cECC in the following: 
 Postoperative bleeding 
 Transfusion requirement  
 Fibrinolysis 
 Coagulation 
 Inflammatory response  
 Haemodilution and haemolysis 
 End-organ protection 
- CK-MB as surrogate marker for myocardial injury 
- Creatinine clearance for renal injury 
- Plasma lactate as surrogate marker for inadequate tissue perfusion  
 Feasibility and safety  
 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
10 
 
2.  
BACKGROUND AND RATIONALE 
 
2.1.  Background 
CABG is the standard treatment of complex ischemic heart disease according to current 
guidelines (1). In Denmark, more than 70 CABG operations are conducted per 100 000 
inhabitants (2). The vast majority of CABG procedures are performed using conventional 
extracorporeal circulation (cECC). The haemodynamic support, the arrested heart and the 
bloodless field allow optimal conditions for a complete myocardial revascularization with a 
low mortality. In Denmark, 30-day mortality for isolated CABG is below 2% (3). However, 
several adverse systemic effects leading to a significant morbidity can be attributed to cECC. 
The contact of blood with air and foreign surfaces causes platelet activation, activation and 
consumption of coagulation factors and a systemic inflammatory response (4,5). 
The miECC concept was developed during the last 15 years with the aim to attenuate the 
adverse systemic effects of cECC. It is based on a closed circuit without a venous cardiotomy 
reservoir to prevent blood-air contact. Many circuits are furthermore treated with a coating to 
increase the haemocompatibilty of the blood in contact with the foreign surfaces. 
Haemodilution is minimized by a low priming volume and low-volume cardioplegia solution. 
Mechanical stress is reduced by use of a centrifugal pump instead of a roller pump and 
avoidance of a cardiotomy suction device. Shed blood from the operative field is removed by 
means of a cell-saver with a washing step to remove debris, activated coagulation factors, and 
free haemoglobin. Strong evidence supports, that the utilization of miECC in CABG can 
attenuate perioperative morbidity. MiECC has been shown to be associated with reduced blood 
loss and transfusion requirements, preserved renal function, reduced incidence of atrial 
fibrillation, and improved myocardial protection (6). No single large multicenter RCT has so 
far been sufficiently powered to demonstrate a survival benefit. However, metaanalyses and a 
propensity score analysis have previously shown a trend towards reduced mortality associated 
with miECC (7–9) and the most recent metaanalysis including 24 RCTs comprising 2770 
patients undergoing heart surgery demonstrated a significant decrease in mortality in miECC 
compared with cECC (10). The implementation of the miECC concept into clinical practice 
remains extremely low worldwide despite strong evidence of its safety and beneficial effects 
(6). The standard treatment in Denmark is to perform CABG with cECC. No Danish center is 
currently using miECC. Implementation of the miECC technique appears to be limited by the 
concerns regarding safety and feasibility of miECC raised by few small-scale human and 
experimental studies (11,12). The lack of a major survival benefit and impending additional 

Protocol  
Final Version  
01.09.2017
 
                                                           
11 
 
costs may contribute to the reluctance within the cardiothoracic community despite the 
promising perspective of the miECC.  
 
2.2.  Rationale 
The suggested mechanisms behind the beneficial effect of miECC are manifold. There is 
compelling evidence that miECC significantly reduces postoperative bleeding and the need for 
perioperative blood transfusion (6). Blood transfusion has been shown to increase mortality 
after CABG independently of the preoperative risk profile (13). Blood transfusion and 
reexploration for bleeding are independently associated with increased risk of major morbidity 
and mortality (14). The reduced need for transfusion of red blood cells is mainly attributed to 
the reduced haemodilution as a consequence of the reduced priming volume of the circuit (6). 
Few studies have focused on the coagulation changes induced by miECC compared to cECC 
(11,15–17) or off-pump CABG (18). Significantly decreased platelet counts and significantly 
increased standard coagulation tests like prothrombin (PT) and activated partial thromboplastin 
times (aPTT) were demonstrated early after CABG with cECC as compared to miECC in one 
randomized controlled trial (16). These findings were confirmed in a small non-randomized 
study (15). Others reported only marginal differences in standard coagulation tests (11,17). 
Postoperative impairment of platelet aggregation was comparable between miECC and cECC 
as measured by multiple electrode aggregometry (17), and postoperative rotation 
thromboelastometry showed no significant differences between cECC and miECC (17). Recent 
studies have suggested decreased thrombin generation as assessed by calibrated automated 
thrombography (CAT) early after CABG with cECC to be associated with increased 
postoperative bleeding (19–21). Thrombin generation assays reflect the plasma haemostatic 
capacity. Multiple pro- and anticoagulant reactions in the coagulation process result in 
thrombin as the final enzyme and major effector of the coagulation cascade. 
We intend to examine the impact of miECC in comparison to cECC on the early postoperative 
thrombin generation potential and whether preservation of the coagulation system integrity 
with miECC is associated with reduced postoperative bleeding and transfusion requirements. 
 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
12 
 
3 
STUDY DESIGN AND OUTCOMES 
 
3.1. Study design 
 
Prospective controlled randomized clinical study at the Department of Cardiothoracic Surgery 
at Aarhus University Hospital, Denmark 
 
3.2. Primary outcome measure 
Primary outcome measures for the randomized comparison between miECC and cECC are: 
 Thrombin generation after weaning from ECC (post protaminization) 
 
3.3. Secondary outcomes measures 
 
Secondary outcome measures for the randomized comparison between miECC and cECC are: 
 Postoperative bleeding as assessed by  
- Cumulated blood loss from the mediastinal and pleural drains 24 hours postoperative 
- Transfusion requirement (packed red blood cells, fresh frozen plasma and platelet 
concentrates) during surgery and in-hospital 
 Postoperative coagulation as assessed by platelet count, aPTT, International Normalized 
Ratio (INR), antithrombin, fibrinogen, prothrombin fragment 1+2 (F 1+2) 
 Postoperative fibrinolytic activity as assessed by clot lysis, and fibrin D-dimer 
 Inflammatory response as assessed by Tumor Necrosis Factor alpha (TNF-α), Interleukin-
panel (IL-panel), C-reactive protein (CRP), white blood count 
 Haemodilution as measured by nadir haematocrit during extracorporeal circulation 
 Haemolysis as assessed by lactate dehydrogenase (LDH) levels 
 Reexploration because of bleeding in-hospital 
 End-organ protection: 
- Postoperative peak creatine kinase-MB (CK-MB) as a surrogate marker for myocardial 
injury 
- Postoperative renal function as reflected by nadir estimated glomerular filtration (eGFR)  
- Intraoperative blood lactate as a surrogate marker for inadequate tissue perfusion 
 Efficacy/safety and feasibility outcomes in-hospital as measured by: 
- Perioperative myocardial infarction as defined in study evaluations 
- Cerebrovascular accident as defined in study evaluations 
- Requirement of renal replacement therapy 
- Repeat revascularization (Reexploration because of ischemia, PCI) 

Protocol  
Final Version  
01.09.2017
 
                                                           
13 
 
- Length of intensive care unit stay (days) 
- Duration of inotropic support and mechanical ventilation (hours) 
- Incidence of atrial fibrillation  
- Infection (requiring antibiotic therapy, wound revision for graft leg infection, superficial 
or deep sternal wound infection) 
- Length of postoperative stay in hospital (days)  
- Intraoperative feasibility of miECC versus cECC 
 30-day MACCE according to the electronic patient record 
- Death from any cause (cardiovascular and non-cardio-vascular mortality). 
- Myocardial infarction  
- Cerebrovascular accident 
- Repeat revascularization 
- Deep sternal wound infection 
 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS 
 
4.1. Inclusion criteria 
 Age > 40 years 
 Non-emergent CABG with ECC 
 Current use of low-dose acetylsalicylic acid 
 Agreement of eligibility by the multidisciplinary heart team 
 
4.2. Exclusion criteria 
 Inability to give informed consent 
 Emergent treatment required (< 24 hours) 
 Concomitant cardiac surgery 
 Previous cardiac surgery 
 Severely reduced kidney function (eGFR < 30ml/min/1.73m2 or on dialysis) 
 Severely reduced ejection fraction (EF < 45%) 
 Diagnosis of bleeding disorders 
 Non-aspirin antiplatelet drugs stopped < 5 days preoperatively (Clopidogrel, Prasugrel, 
Ticagrelor, Ticlopidine) 
 Current use of systemic glucocorticoid therapy 

Protocol  
Final Version  
01.09.2017
 
                                                           
14 
 
 Current use of vitamin K antagonists or new oral non-vitamin K anticoagulants 
 Platelet count > 450 or  <100 x 109/l prior to surgery 
 Pregnant women or women of child bearing potential without negative pregnancy test 
 Active participant in any other intervention trial 
 
4.3. Study enrollment procedures and informed consent 
Consecutive patients with non-emergent multivessel coronary artery disease scheduled for 
primary isolated CABG with ECC will be screened for eligibility by the multidisciplinary heart 
team. Eligible patients will together with the information regarding their scheduled CABG 
receive written information regarding the study (Deltagerinformation om deltagelse i et 
videnskabeligt forsøg) and a brochure regarding volunteer’s rights in a health science research 
project (Forsøgspersoners rettigheder i et sundhedsvidenskabeligt forskningsprojekt). 
Information will include the recommendation to bring a companion on admission and 
emphasize that participation is voluntary and that she/he can any time without reason withdraw 
their consent and drop out of the project. Patients are admitted one to three days prior to 
surgery. Patients interested in participation will receive verbal information about the study by 
the consultant cardiac surgeon in a quiet and undisturbed environment. The investigator will 
ensure that the patient is adequately informed both verbally and in writing about the study, 
background, design, risks, side effects, disadvantages, benefits and usefulness. Written consent 
is signed on the day of surgery giving the patient minimum 24 hours opportunity to ask 
questions and to reconsider. Copies of the consent form will be given to the patients. After 
informed consent has been obtained, the REDCap Randomization Module will allocate the 
patients to the miECC- or cECC-cohort in a 1:1 ratio (22). Patients will be asked permission to 
store blood samples in two kinds of biobank located at Department of Clinical Biochemistry, 
Aarhus University Hospital. This is stated clearly in the written information received by all 
patients. The first research biobank is essential for the study, as it will store frozen plasma 
samples for batch analysis of thrombin generation, F 1+2, and inflammatory markers. Eventual 
excessive material will be transferred to the biobank for future unspecified research. This 
biobank will be used for future, but not yet specified, projects focusing on coagulation 
research. Its content will only be used after approval from The Central Denmark Region 
Committees on Health Research Ethics. The samples will be destroyed ten years after 
completion of the project. 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
15 
 
If a study participant wishes his blood sample to be removed from the biobank after 
termination of the study, this will be granted, but previously produced results will not be 
deleted. 
 
4.4. Study duration and follow-up 
To adequately project the expected enrolment rate, we performed a retrospective analysis of all 
patients who underwent elective CABG in 2016 at the Department of Cardiothoracic and 
Vascular Surgery of Aarhus University Hospital based on our quality database (Western 
Denmark Heart Registry). In 2016, we identified 149 patients, who met the major in-and 
exclusion criteria of the current study (elective CABG with ECC, age > 40 years, no prior heart 
surgery, no severely reduced kidney function, no severely reduced ejection fraction, no current 
use of systemic glucocorticoid therapy). We expect approximately 80% of patients to fulfil the 
additional in-and exclusion criteria. We presume at the most 60% of eligible patients to give 
informed consent. To include 60 patients, the approximate duration of the enrolment period is 
one year. 
 
5. 
MATERIALS AND METHODS 
 
5.1. Study treatment 
In both groups, the same anticoagulation regimen and surgical procedure is employed. After 
median sternotomy, a pedicled left internal mammary artery and a no-touch saphenous vein 
graft are harvested. Unfractionated heparin is administered with a target activated coagulation 
time of >400 seconds. Additional boluses of heparin are administered as required during the 
procedure.  
Heparin and protamine doses are assessed by the HMS Plus® Hemostasis Management System 
(Medtronic International, Tolochenaz, CH). Tranexamic acid as an antifibrinolytic agent is 
given on induction of anaesthesia (2 g), on commencement of ECC (1 g), and after weaning 
from ECC (1 g).  
A 24-F arterial cannula, a 29/29 F dual-stage venous cannula, and a combined vent-
/cardioplegia cannula in the ascending aorta are utilized. Normothermia and goal-directed 
perfusion management are applied (maintaining mixed venous oxygen saturation (SvO2)  
>65% as measured by in-line blood gas monitoring on the venous return line and the oxygen 
delivery (DO2) level above >270 ml/min/m2).  
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
16 
 
After completion of the distal anastomoses and removal of the aortic cross-clamp, the proximal 
anastomosis is performed with an aortic partial clamp. Protamine is administered to neutralize 
heparin after weaning from ECC. Chest tubes 32F are inserted to drain the left pleural cavity 
and the mediastinum. 
 
MiECC 
The miECC closed circuit consists of polyvinylchloride and silicone tubing coated with a 
hydrophilic biosurface (Balance® Biosurface) to reduce platelet adhesion and activation. It 
contains a centrifugal pump (Affinity™ CP centrifugal blood pump AP40, Medtronic 
International, Tolochenaz, CH), an automatic venous air removal device (Affinity® VARD, 
Medtronic International, Tolochenaz, CH), and an oxygenator with integrated arterial filter and 
a membrane surface of 2.5 m2 (Affinity Fusion®, Medtronic International, Tolochenaz, CH). 
Ante- and retrograde autologous priming is aimed for in all patients to reduce the effective 
priming volume of the system to 400 to 700 ml. The shed blood is collected and processed with 
a cell-saving device applying Ringer’s solution (Autolog®, Medtronic International, 
Tolochenaz, CH). Myocardial protection is accomplished using antegrade intermittent cold 
modified blood Calafiore cardioplegia every 20 minutes. A soft-shell reservoir bag is used to 
collect blood from the vent and to regulate the volume. 
  
cECC 
The cECC circuit consists of uncoated polyvinylchloride and silicone tubing (Costumpack 
M450311F, Medtronic International, Tolochenaz, CH), a hard-shell venous reservoir, an 
oxygenator with integrated arterial filter (Affinity Fusion®, Medtronic International, 
Tolochenaz, CH). A roller pump (Stöckert S5, Munich, Germany), and an oxygenator with 
integrated arterial filter and a membrane surface of 2.5 m2 (Affinity Fusion®, Medtronic 
International, Tolochenaz, CH). The flow rate for the cECC system is set at 2.4 L/min/m2. The 
priming volume of the system is 1400 mL of Ringer’s solution. Myocardial protection is 
accomplished using antegrade intermittent cold blood Harefield cardioplegia every 20 minutes. 
 
Anaesthesia 
All preoperative cardiac medication including low-dose aspirin is continued until the day prior 
to surgery.  Other medication affecting haemostasis is discontinued according to institutional 
guidelines. β-blocking agents are continued until and including the day of operation.  
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
17 
 
Anaesthesia is induced according to local standards (Propofol, Sufentanil, and Rocuronium in a 
weight-adapted dose), maintained with Propofol infusion and Sevoflurane as well as repeated 
injections of Sufentanil and Rocuronium according to the clinical need. In the operating room, 
patients are monitored with five-lead electrocardiography, radial artery pressure, a central 
venous catheter in internal jugular vein, a thermo dilution pulmonary artery catheter (Swan-
Ganz CCOmbo CCO/SvO2, Edwards Lifesciences LLC, Irvine, CA), oxygen pulse oximetry, 
transoesophageal echocardiography, and temperature monitoring. The patient's temperature is 
maintained at 37 °C by means of a heater cooler unit during ECC and a forced-air warming 
device off ECC. Excessive fluid administration is avoided to reduce haemodilution. 
Intraoperative positioning of the patient and low-dose vasoactive agents are used to keep mean 
arterial pressure between 50 and 60 mmHg during ECC. 
 
Postoperative management 
Patient sedation is maintained with an intravenous Propofol infusion, until arrival at intensive 
care unit (ICU). Upon arrival at ICU, a focus-assessed transthoracic echo (FATE) is performed 
by the attending anaesthesiologist to exclude pericardial or pleural effusions, and the patient is 
extubated and observed overnight at the ICU. All patients receive oral Paracetamol 1g and 
additional non-steroidal anti-inflammatory drugs (Ketorolac) and/ or morphine-like analgesics 
(morphine or oxycodone) as required. During the postoperative period, the chest tubes are 
removed at the earliest ten hours postoperative, following mobilization, on the condition that 
total drainage is decreasing and less than 200 mL over a four hour period, and without air 
leakage. Perioperative glucocorticoids given to prevent post-operative nausea and vomiting are 
registered. Low-dose acetylsalicylic acid and statin therapy is resumed on the first 
postoperative day and continued lifelong. Dalteparin 5000 IE are given once daily from the 
first postoperative day to prevent deep venous thrombosis until fully mobilized. 
 
5.2. Laboratory measurements 
 
Blood sampling 
All analyses are performed at the Department of Clinical Biochemistry at Aarhus University 
Hospital, Denmark. Blood is collected into vacuum test tubes containing the following 
additives: 3.2% sodium citrate for thrombin generation and other coagulation tests as well as 
inflammatory markers; lithium heparin for CRP, LDH, CK-MB, creatinine/ eGFR, lactate and 
intraoperative hæmatocrit, and EDTA for haematological analyses. Blood samples for 

Protocol  
Final Version  
01.09.2017
 
                                                           
18 
 
haematological analyses, the majority of coagulation tests (aPTT, INR, antithromin, 
fibrinogen), CRP, LDH, lactate, creatinine, eGFR and CK-MB analyses are analyzed within 90 
minutes of sampling. 
Blood samples during surgery and on ICU (T0-T4) are taken through the sheath of the central 
venous line, through which no heparin is administered. After flushing the catheter, fluid is 
withdrawn until blood is visualized in the syringe. Additional 2ml (minimum waste) are 
discarded prior to blood sampling. 
 
Thrombin generation 
 
Thrombin is an essential part of the coagulation cascade and is responsible for converting 
fibrinogen to fibrin. Thrombin generation is a measure of the ability to generate thrombin in 
platelet poor plasma. We use the Fluoroskan Ascent plate reader (Thermo Scientific, Helsinki, 
Finland) for measurement of fluorogenic activity in the microtitre wells. Data are transformed 
to a computer and processed by the Thrombinoscope® software package (Thrombinoscope 
BV, Maastricht, The Netherlands). From the thrombograms, we derive numerical values for the 
following parameters: a) lagtime in minutes (start of thrombin activity), b) peak thrombin 
activity in nmol, c) time-to-peak in minutes, and d) total endogenous thrombin generation 
potential (area under the curve) in nmol/minute. 
 
Coagulation tests 
APTT, INR, antitrombin and fibrinogen are measured by CS2100i (Sysmex, Kobe, Japan).  
F1+2 is determined by ELISA (Enzygnost, Siemens Healthcare Diagnostics) 
 
Fibrinolysis tests 
 
Clot lysis is evaluated using an in-house dynamic turbidimetric assay. Briefly, in a 96-well 
microplate, citrated platelet poor plasma is mixed with a reaction solution including tissue 
factor and tissue plasminogen activator. Plates are read using a Victor X4 (Perkin Elmer, 
Turku, Finland), and the following parameters are recorded: a) clot maximum absorbance 
(reflecting clot density), b) clot lysis time (reflecting fibrinolysis time), and c) area under the 
curve (a measure integrating clot formation and degradation). 
Fibrin d-dimer is determined employing the CS2100i (Sysmex, Kobe, Japan). 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
19 
 
Inflammatory markers 
TNFα, and the interleukin panel are measured according to the manufacturers' instruction with 
enzyme-linked immunosorbent assays (V-PLEX Plus Proinflammatory Panel 1 (human) kit, 
MSD, Rockville, MA, USA). 
 
Standard Biochemical Parameters 
 Complete blood counts (haemoglobin, white blood cell count, platelet count, immature 
platelet count, and immature platelet fraction) are performed using a Sysmex XE-5000 
haematology analyzer (Sysmex, Kobe, Japan) 
 Plasma CRP, LDH, CK-MB, creatinine are measured using the Cobas® 6000 (Roche, 
Basel, Switzerland). eGFR per 1.73 m2 body surface area (eGFR/1,73m2) is calculated 
according to the Chronic Kidney Disease-Epidemiology Collaboration equation (CKD-EPI) 
 Intraoperative haematocrit and blood lactate are determined using the ABL800 FLEX 
(Radiometer Medical A/S, Denmark). 
 
The total amount of blood for the project from each participant is specified below 
 
Research biobank 
Plasma for thrombin generation, F1+2, inflammatory markers and clot lysis is stored in a 
biobank (-80°C freezer) and analyzed as batch analyses. 
 
Biobank for future unspecified research 
It will store blood samples in coded form at minus 80°C for later analysis (2 ml serum and 4 ml 
EDTA plasma). Additional analyses will only be performed after approval from the Central 
Denmark Region Committees on Biomedical Research Ethics.  
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
20 
 
6 
STUDY EVALUATIONS 
 
6.1 
Description of evaluations 
Screening evaluation 
Eligibility will be assessed by the Heart Team at the multidisciplinary conference, based on 
clinical information and laboratory analyses. On admission, the predicted perioperative 
mortality is calculated with the European System for Cardiac Operative Risk Evaluation (23). 
Cardiac, anti-inflammatory (NSAID), statin and anticoagulation medications are recorded.  
 
Blood sampling 
Blood samples including serological parameters will be obtained at the following time points:  
 T0; preoperative after induction of anaesthesia (after insertion of central venous line) 
 T1; after weaning of the ECC prior to protaminization  
 T2; 10 minutes after full protaminization 
 T3; six hours after the end of the ECC 
 T4; 1. postoperative day (16-20 hours following end of surgery) 
There will be drawn 12 ml blood per blood sample for analysis of prespecified study 
parameters, in total a volume of 60 ml blood obtained solely for the project. Provided the 
patients’ consent, additional 6 ml per blood samples will be drawn for the research biobank, in 
total a volume of 30 ml blood. Thus, the total volume of blood required for the current study is 
100 ml. Results of routine blood samples to monitor organ function and inflammation on the 
second (T5), third (T6), and fourth (T7) postoperative day will be included in the study. 
 
Evaluation of cerebrovascular accidents 
Any neurological dysfunction consistent with a cerebrovascular accident will prompt clinical 
quantification of the severity of the impairment by the NIHSS: 0= No stroke symptoms; 1-4 = 
Minor stroke; 5-15= Moderate stroke; 16-20= Moderate to severe stroke; 21-42= Severe stroke 
(24). Any case of suspected stroke is verified by CT scanning to exclude bleeding. Patients 
with clinical signs of stroke without corresponding findings on CT scanning will be examined 
by MRI. Symptoms indicative of stroke with resolution within 24 hours without imaging 
evidence of ischemic injury defined TCI. 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
21 
 
Evaluation of perioperative MI 
A perioperative MI is defined according to the new definition of clinically relevant MI of the 
Society for Cardiovascular Angiography and Interventions (25). In patients with normal 
baseline CK-MB, the peak CK-MB measured within 48 hours of the procedure rises to ≥10 × 
the local laboratory upper limit of normal, or to ≥5 × upper limit of normal with new 
pathologic Q-waves in ≥2 contiguous leads or new persistent left bundle branch blok. 
Electrocardiograms (ECG) are performed by routine at arrival on ICU, on the first 
postoperative day and on discharge from hospital. 
 
Intraoperative feasibility of miECC versus cECC 
The feasibility of CABG procedure with miECC will be assessed in comparison to cECC. The 
operating team will evaluate the following aspects at the end of the procedure: 
Serious adverse device events like air lock, dissection, bleeding that exceeds the capacity of the 
cell saver, air emboli, stop of the circuit, and conversion to cECC are registered  as described 
in safety aspects. 
In addition, technical aspects will be registered: postoperative fluid gain in milliliters, and  
venous drainage, visibility due to blood in the operative field, and the ability to maintain SvO2 
>65% graded into the categories “perfect”, “impaired” or “insufficient”. 
 
30 day assessment 
The electronic patient record is reviewed 30 days after CABG with regards to adverse events: 
 Death of any cause 
 Death due to cardiac causes (MI, arrhythmia congestive heart failure) 
 Death due to other vascular causes (cerebrovascular accident, pulmonary embolus, 
dissection, or bleeding event ) 
 Death due to non-cardiovascular causes including any other cause of death  
 Myocardial infarction 
 Cerebrovascular  accident  
 Repeat revascularization 
 Major bleeding 
 Deep sternal wound infection 
Other non-specified serious adverse events will be captured 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
22 
 
6.2 
Schedule of evaluations 
 
 
Admission 
Induction 
anaesthesia 
Prior 
protamin 
After 
protamin 
6 hours po 
Day 1 po 
Day 2 po 
Day 3 po 
Day 4 po 
Discharge 
Day 30 po 
 
 
T0 
T1 
T2 
T3 
T4 
T5 
T6 
T7 
 
 
Initiation procedures 
 
 
 
 
 
 
 
 
 
 
 
Eligibility 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
 
 
 
 
 
 
 
 
 
 
 
Informed consent 
 
 
 
 
 
 
 
 
 
 
 
Laboratory tests 
 
 
 
 
 
 
 
 
 
 
 
Thrombin generation 
 
 
 
 
 
 
 
 
 
 
 
Coagulation tests 
 
 
 
 
 
 
 
 
 
 
 
Inflammatory marker 
TNFα, IL-6, IL-1β, IL-8 
 
 
 
 
 
 
 
 
 
 
 
Hæmatocrit, lactate* 
 
 
 
 
 
 
 
 
 
 
 
LDH, CK-MB* 
 
 
 
 
 
 
 
 
 
 
 
CRP, WBC* 
 
 
 
 
 
 
 
 
 
 
 
Creatinin, eGFR* 
 
 
 
 
 
 
 
 
 
 
 
ECG* 
 
 
 
 
 
 
 
 
 
 
 
Medication 
NSAID, glucocorticoids 
 
 
 
 
 
 
 
 
 
 
 
Efficacy/safety 
outcomes 
 
 
 
 
 
 
 
 
 
 
 
Serious adverse events 
 
-------------------- Continious reporting ----------------------- 
 
Adverse events 
 
 
 
 
 
 
 
 
 
 
 
 
* Results of routine laboratory and electrocardiogram (ECG) analyses to be included in the study 

Protocol  
Final Version  
01.09.2017
 
                                                           
23 
 
7.  
SAFETY ASPECTS 
 
7.1. Insurance 
The investigators will be covered by the liability and work injury insurance taken out by 
Aarhus University Hospital. Participants are covered by the act on complaints and 
compensation within the health care system. 
 
7.2.  Adverse events and serious adverse events 
Adverse events  
Adverse events are defined as unfavorable and unintended symptoms or signs (including 
abnormal laboratory findings), which occur during the study up to 30 days after CABG. 
Adverse events are recorded regardless of their relationship to the study intervention. 
 Periprocedural myocardial infarction 
 Other intraoperative complications 
 Atrial fibrillation requiring pharmacological therapy or defibrillation  
 Reexploration for bleeding 
 Requirement of transfusion 
 Prolonged stay on intensive care unit (> 24 hours) 
 Prolonged requirement of mechanical ventilation 
 Requirement of pharmacological haemodynamic support  
 Reintervention for graft occlusion or myocardial ischaemia (Surgery or PCI) 
 Deep sternal wound infection 
 Superficial wound infection requiring revision 
 Postoperative infection requiring antibiotic therapy  
Adverse events will be recorded after surgery, on discharge from the ICU, on discharge from 
hospital, and after 30 days based upon the electronic patient record. Unsolicited events will be 
captured 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
24 
 
Serious adverse events  
Serious adverse events are defined, as any untoward medical occurrence that results in death, is 
life threatening, requires inpatient hospitalization or prolongation of existing hospitalization, or 
results in persistent or significant disability/incapacity. The following events within 30 days are 
defined as serious adverse events: 
 Any death occurring in-hospital 
 Stroke  
 Postoperative requirement of renal replacement therapy 
 Requirement of temporary mechanical circulatory support  
 
Serious adverse device effects 
Serious intraoperative complications are defined as air lock, dissection, bleeding exceeding the 
capacity of the cell-saver, air emboli, stop of the circuit, and conversion to cECC. 
 
All serious adverse events will be recorded immediately after occurrence.  
 
 
7.3.  Reporting procedures and follow-up 
The assessment of the causal relationship between an adverse event and the study intervention 
is a clinical decision made by the steering committee. The assessment is based on whether 
there is a reasonable possibility that the study intervention has caused the event. The outcome 
of an adverse will be documented as: resolved/recovered, resolved/recovered with sequelae, 
not resolved/recovered, fatal, or unknown. Stopping rules are described under statistics 
considerations. 
 
 
8.  
STATISTICS CONSIDERATIONS 
 
8.1. General design issues  
Treatment group allocation cannot be concealed for the operating team, but participants, other 
members of the treatment team, laboratory personal and other practitioners administering 
postoperative care will be blinded regarding the allocation to ensure unbiased ascertainment of 
outcomes. 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
25 
 
8.2. Sample size and randomization  
Our primary outcome measure is the difference in thrombin generation expressed as 
endogenous thrombin generation potential between miECC and cECC patients after weaning of 
the ECC (post protaminization). Thrombin generation data (measured by the same method as 
ours) has recently been published on patients undergoing CABG with cECC just prior to 
surgery (19). According to Moorlag et al., mean endogenous thrombin generation potential in 
platelet poor plasma is 1138.1 mol/L x min with a standard deviation at 268.2 mol/L x min in 
patients undergoing CABG with cECC prior to surgery (19). Choosing a minimal relevant 
difference (MIREDIF) of 250 mol/L x min, a significance level of 5% (2a), and a statistical 
power of 90% (1-b) we have to include 25 participants in each group. In order to ensure a 
complete dataset and assuming a dropout rate of about 20%, we aim to include a total 
of 60 participants. 
 
8.3.  Stopping rules 
 
Intraoperative death will temporarily suspend enrollment and study intervention until a safety 
review by the steering commitee is convened. Other adverse events such as air lock of the ECC 
circuit, perioperative myocardial infarction and stroke trigger a safety review by groups by the 
steering committee. The findings are used to determine whether the study should continue per 
protocol, proceed with caution, be further investigated, be discontinued, or be modified and 
then proceed. Cases of Suspected Unexpected Severe Adverse Reactions (SUSAR) will be 
reported to the Central Denmark Region Committees on Biomedical Research Ethics according 
to ”Vejledning til indberetning af mistænkte uventede og alvorlige bivirkninger set i kliniske 
forsøg”.  
Patients enrolled may withdraw voluntarily from study participation at any time and for any 
reason. If voluntary withdrawal occurs, the subject will be asked for permission to be followed 
for clinical outcome. 
 
8.4. Data analyses 
All primary and secondary end points will be analyzed both on an intention-to-treat and on a 
per protocol principle. For per protocol analyses, only patients who received the appropriate 
treatment according to their randomization and have a complete dataset available at all five 
perioperative time points (T0-T4) will be included. Tracking of outcome measures will begin 
at randomization and continue until death or end of follow-up (30 days after CABG). No 
formal interim analysis will be performed. Continuous variables will be presented as mean ± 

Protocol  
Final Version  
01.09.2017
 
                                                           
26 
 
standard deviation (SD) if normally distributed, otherwise as median with interquartile range 
(25th and 75th percentile), minimum and maximum values. Discrete variables will be 
presented in frequencies and percentages. Kaplan-Meier plots will be constructed to visualize 
time to event variables and log-rank tests will be used. 
All statistical analyses will be done using Stata 10.1 SE (Stata Corp., College Station, USA). 
Statistical consultation is provided by the Department of Biostatistics, Aarhus University. 
 
 
9 
DATA COLLECTION AND QUALITY ASSURANCE 
 
9.1. Data collection forms 
Study data are collected and managed using REDCap electronic data capture tools hosted at 
Aarhus University Hospital (22). REDCap (Research Electronic Data Capture) is a secure, 
web-based application designed to support data capture for research studies, providing: 1) an 
intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and 
export procedures; 3) automated export procedures for seamless data downloads to common 
statistical packages; and 4) procedures for importing data from external sources. An electronic 
Case Report Form (CRF) will be constructed for data registration.  
 
9.2 
Data management  
 Data will be handled, processed, and archived according to the guidelines of the Data 
Protection Agency. Each participant will be given an identification number at enrolment. Each 
identification number will have a Case Report Form (CRF). The list over identification codes 
will be deleted at the end of the study. All trial data including Trial Master File, CRF, the 
source datasheet of the CRF, and the list over identification codes will be stored in the external 
server REDCap with continuous backup. REDCap data are kept for 10 years. Information on 
study participants will be protected according to the Act of Processing of Personal Data, and 
the Health Act. 
 
9.3. Training 
The sponsor Ivy S. Modrau and co-investigator Debbie Richards Halle will provide GCP and 
NIHSS training certificate prior to start of the study. 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
27 
 
9.4. Protocol deviations 
Conversions from miECC to cECC will be documented and reviewed as described in safety 
aspects. Data from these patients will be analyzed according to the intention-to-treat principle 
but will be excluded from the per protocol analysis. 
 
 
10 
ECONOMY 
 
The Department of Cardiothoracic and Vascular Surgery at Aarhus University Hospital covers 
the running expenses for both surgical interventions. Funding for publication of the protocol, 
laboratory analysis, statistical assistance, and expenses for presentation at scientific meetings, 
data retrieval will be continuously applied for at non-commercial private and public 
foundations. 
 
 
11 
ETHICAL CONSIDERATIONS 
 
11.1. Risk of study intervention 
Few publications have raised concerns regarding miECC as compared to cECC due to 
ventricular dilatation, loss of a bloodless field and the risk of air lock of the closed circuit 
during perfusion (11,12). However, these reports are anecdotal, and large-scale controlled 
clinical trials have confirmed the safety of modern miECC systems (6). We apply a miECC 
system with the following integrated safety measures: 1) an integrated venous air removing 
device to prevent air lock, 2) an electric clamp system to stop circulation if air should have 
passed the bubble trap, 3) an integrated of collapsible soft-shell reservoir to make blood 
volume management easier 4) an aortic root vent to reduce blood in the surgical field, 5) a cell-
saving device to collect and process shed blood from the operating field, and 6) a conventional 
heart lung machine on stand-by to allow rapid conversion to a conventional open circuit in case 
of unexpected emergent intraoperative scenarios as the ultimate safety measure.  
We believe that the risk of study participation is minimal and outweighed by the value of the 
knowledge gained through this study, which will be of potential benefit for future patients 
undergoing coronary bypass surgery. Participants will not derive any individual benefit from 
study participation. 
The current study involves no increased risk of discomfort or bruising due to blood sampling, 

Protocol  
Final Version  
01.09.2017
 
                                                           
28 
 
as the blood samples are taken through the central venous line during at the first 5 time points 
(T0-T4). The results of routine blood samples regarding organ dysfunction and inflammation at 
the following time points (T5-T7) are included in the study. The total volume of 60 ml for 
prespecified blood samples and 30 ml for research biobank drawn over a period of 5 days is 
considered of minimal risk for the participants 
 
11.2. Conflict of interest 
 
The study has been initiated solely by the investigators. The investigators have no conflict of 
interest to declare and no commercial interest to conduct the study.  
 
11.3. Approval 
 
The study is approved by the Central Denmark Region Committees on Biomedical Research 
Ethics (Nr 1-10-72-150-17) and the Danish Data Protection Agency (Nr. 1-16-02-188-17). The 
study is registered at www.clinicaltrials.gov (ClinicalTrials.gov ID: NCT03216720). The 
protocol follows the Declaration of Helsinki-II and Consort guidelines. 
 
 
12  
STUDY ORGANIZATION 
 
12.1 Steering committee 
The main role of the steering committee is to monitor and supervise the progress of the trial. 
The steering committee consists of the sponsor Ivy S. Modrau, Department of Cardiothoracic 
and Vascular Surgery, the co-investigator professor Anne-Mette Hvas, Department of Clinical 
Biochemistry and professor J. Michael Hasenkam, Principal of the Scandinavian School of 
Cardiovascular Technology, all Aarhus University Hospital. 
 
12.2 Delegation of study-related tasks 
The principal investigator (PI) is responsible for personally conducting or supervising the study. 
Certain study-related tasks delegate to co-investigators and study staff.  
 Screening of patients regarding eligibility for the study will be conducted by the 
multidisciplinary Heart Team consisting of interventional cardiologist and cardiac surgeon 
based on electronic patient report including laboratory data, coronary angiogram and other 
imaging evaluations. 
 The PI arranges that eligible patients receive written information regarding the study 
together with the information regarding their scheduled CABG. 

Protocol  
Final Version  
01.09.2017
 
                                                           
29 
 
 The medical histories and assessment of inclusion/exclusion criteria are collected by the PI 
and the co-investigator perfusionist aspirant Debbie Richards Halle.   
 Oral information about the study is given to the patient at admission one to three days prior 
to surgery by one of the licensed physician investigators listed in the protocol.   
 The PI will ensure the participant has received sufficient oral and written information 
regarding the trial and obtain informed consent on the morning of surgery. 
 The operation team (perfusionist, anaesthesiologist, surgeon) will collect the intraoperative 
data including adverse events on respective CRFs. 
 The primary study endpoints cumulated postoperative blood loss from drains and 
transfusion requirement are assessed by the PI or the co-investigator perfusionist aspirant 
Debbie Richards Halle.  
 The adverse events in-hospital are recorded by the PI or the co-investigator perfusionist 
aspirant Debbie Richards Halle.  
 The Department of Clinical Biochemistry at Aarhus University Hospital is responsible for 
collection and analyses of laboratory data throughout the study  
 NIHSS will be performed by certified co-investigators. 
 Any co-investigator will record serious adverse events as soon as they occur 
 The PI evaluates adverse events 30 days postoperatively by review of the electronic patient 
record and signs the CRF 
 The Department of Clinical Biochemistry at Aarhus University Hospital is responsible for 
collection, anonymization and appropriate use of blood samples for the biobank. They 
guarantee the complete destruction of the biobank after 10 years  
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
30 
 
13 
COOPERATION AND PUBLICATION POLICY 
 
The study is performed in collaboration between the Department of Cardiothoracic and 
Vascular Surgery, the Department of Clinical Biochemistry, Center for Haemophilia and 
Thrombosis, and the Department of Anaesthesiology and Intensive Care, Aarhus University 
Hospital. Department of Clinical Biochemistry has all the equipment and knowledge needed 
for carrying out the biochemical analyses. 
The technique of miECC was implemented at the Department of Cardiothoracic and Vascular 
Surgery, Aarhus University Hospital in 2016 following a learning visit of the operating team 
(surgeon, perfusionist, anaethesiologist, operating room nurse) to Doctor Aschraf El-Essawi at 
the Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany. 
In addition, the Scandinavian School of Cardiovascular Technology at Aarhus has close 
collaboration with chief perfusionist Adrien Bauer at the Department of Cardiothoracic 
Surgery at the MediClin Heart Centre Coswig, Germany Hospital. Perfusionist aspirant Debbie 
Richards will visit the center in Coswig for exchange of experience in May 2017. Both centers' 
have long-term experience with miECC and participated in the largest multicenter RCT 
regarding miECC so far (26). 
 
We intend to publish the protocol in the BioMed Central Journal of Cardiothoracic Surgery. 
Results, whether positive, negative or inconclusive, will be published in the best peer-reviewed 
scientific cardiothoracic journals possible and be presented at international conferences 
meetings in the field of cardiothoracic surgery. The part of the study concerning inflammatory 
markers will serve as the basis for the master thesis of perfusionist aspirant Debbie Richards 
Halle at the Scandinavian School of Cardiovascular Technology. The results of the master 
thesis are to be published as an article in a peer-reviewed journal by Debbie Richards as first 
author. All above-mentioned investigators are expected to receive authorships according to the 
Vancouver declaration.  
Participants will be able to request a copy of the results of the study from the principle 
investigator at the end of the study. 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
31 
 
14  
PLANNED TIMELINE 
Protocol complete  
 
 
May 2017 
Approval from Science Ethics committee 
 
 
August 2017 
Enrollment 
September 2017  
- 
September 2018 
Data collection 
September 2017 
- 
Oktober 2018 
Data analysis 
Oktober 2018  
-  
February 2019   
Publication 
 
 
2019 
 
 
15  
PERSPECTIVES 
MiECC has emerged as a promising treatment to attenuate several adverse systemic effects that 
are attributed to extracorporeal circulation leading to a significant morbidity. However, many 
questions regarding the underlying mechanisms remain unanswered. The present study will 
clarify the effect of different ECC systems on the coagulation system and its proposed link to 
postoperative blood loss and transfusion requirement. In addition, analysis of inflammatory 
markers in the postoperative period will contribute to the understanding of the systemic 
inflammatory response following ECC. Finally, the current study will add to the overall 
clinical evidence regarding clinical efficacy, safety and feasibility of miECC in CABG. 
 
 
 
 

Protocol  
Final Version  
01.09.2017
 
                                                           
32 
 
16 
REFERENCES 
1.  
Windecker S, Kolh P, Alfonso F, Collet J-P, Cremer J, Falk V, et al. 2014 ESC/EACTS 
Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization 
of the European Society of Cardiology (ESC) and the European Association for Cardio-
Thoracic Surgery (EACTS). Eur Hear J. 2014;46:517–92.  
2.  
Eurostat Statistics explained. Cardiovascular diseases statistics [Internet]. 2016 [cited 2017 
Mar 19]. Available from: http://ec.europa.eu/eurostat/statistics-
explained/index.php/Cardiovascular_diseases_statistics 
3.  
Danish Heart Registry [Internet]. [cited 2017 Apr 28]. Available from: www.dhreg.dk 
4.  
Besser M, Klein A. The coagulopathy of cardiopulmonary bypass Martin. Crit Rev Clin Lab 
Sci. 2017;47:197–212.  
5.  
Kraft F, Schmidt C, Aken H Van, Zarbock A. Inflammatory response and extracorporeal 
circulation. Best Pr Res Clini Anaesth. 2015;29:113–23.  
6.  
Anastasiadis K, Murkin J, Antonitsis P, Bauer A, Ranucci M, Gygax E, et al. Use of minimal 
invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential 
benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies 
international Society (MiECTiS). Interact Cardiovasc Thorac Surg. 2016;22:647–62.  
7.  
Zangrillo A, Garozzo FA, Biondi-Zoccai G, Pappalardo F, Monaco F, Crivellari M, et al. 
Miniaturized cardiopulmonary bypass improves short-term outcome in cardiac surgery: A 
meta-analysis of randomized controlled studies. J Thorac Cardiovasc Surg. 2010;139:1162–9.  
8.  
Biancari F, Rimpiläinen R. Meta-analysis of randomised trials comparing the effectiveness of 
miniaturised versus conventional cardiopulmonary bypass in adult cardiac surgery. Heart. 
2009;95:964–9.  
9.  
Koivisto S-P, Wistbacka J-O, Rimpiläinen R, Nissinen J, Loponen P, Teittinen K, et al. 
Miniaturized versus conventional cardiopulmonary bypass in high-risk patients undergoing 
coronary artery bypass surgery. Perfusion. 2010;25(2):65–70.  
10.  
Anastasiadis K, Antonitsis P, Haidich A-B, Argiriadou H, Deliopoulos A, Papakonstantinou 
C. Use of minimal extracorporeal circulation improves outcome after heart surgery; a 
systematic review and meta-analysis of randomized controlled trials. Int J Cardiol. 
2013;164:158–69.  
11.  
Nollert G, Schwabenland I, Maktav D, Kur F, Christ F, Fraunberger P, et al. Miniaturized 
cardiopulmonary bypass in coronary artery bypass surgery: Marginal impact on inflammation 
and coagulation but loss of safety margins. Ann Thorac Surg. 2005;80:2326–32.  
12.  
Aboud A, Liebing K, Börgermann J, Ensminger S, Zittermann A, Renner A, et al. Excessive 
negative venous line pressures and increased arterial air bubble counts during miniaturized 
cardiopulmonary bypass: An experimental study comparing miniaturized with conventional 
perfusion systems. Eur J Cardiothorac Surg. 2014;45:69–74.  

Protocol  
Final Version  
01.09.2017
 
                                                           
33 
 
13.  
Paone G, Brewer R, Theurer PF, Bell GF, Cogan CM, Prager RL. Preoperative predicted risk 
does not fully explain the association between red blood cell transfusion and mortality in 
coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2012;143:178–85.  
14.  
Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, et al. 
Morbidity of bleeding after cardiac surgery: Is it blood transfusion, reoperation for bleeding, 
or both? Ann Thorac Surg. 2011;91:1780–90.  
15.  
Zeitani J, Buccisano F, Nardella S, Flaminio M, Prati P, Chiariello G, et al. Mini-
extracorporeal circulation minimizes coagulation abnormalities and ameliorates pulmonary 
outcome in coronary artery bypass grafting surgery. Perfusion. 2013;28(4):298–305.  
16.  
Anastasiadis K, Asteriou C, Deliopoulos A, Argiriadou H, Karapanagiotidis G, Antonitsis P, 
et al. Haematological effects of minimized compared to conventional extracorporeal 
circulation after coronary revascularization procedures. Perfusion. 2010;25(4):197–203.  
17.  
Rahe-Meyer N, Solomon C, Tokuno ML, Winterhalter M, Shrestha M, Hahn A, et al. 
Comparative assessment of coagulation changes induced by two different types of heart-lung 
machine. Artif Organs. 2010;3(1):3–12.  
18.  
Scrascia G, Rotunno C, Guida P, Conte M, Amorese L, Margari V, et al. Haemostasis 
alterations in coronary artery bypass grafting: Comparison between the off-pump technique 
and a closed coated cardiopulmonary bypass system. Interact Cardiovasc Thorac Surg. 
2013;16: 636–42.  
19.  
Moorlag M, Schurgers E, Krishnamoorthy G, Bouwhuis A, Lindhout T, Kelchtermans H, et 
al. Near Patient Thrombin Generation in Patients Undergoing Elective Cardiac Surgery. J 
Appl Lab Med. 2017;1(6):613–25.  
20.  
Bosch Y, Al Dieri R, Ten Cate H, Nelemans P, Bloemen S, Hemker C, et al. Preoperative 
thrombin generation is predictive for the risk of blood loss after cardiac surgery: a research 
article. J Cardiothorac Surg. 2013;8:154.  
21.  
Coakley M, Hall JE, Evans C, Duff E, Billing V, Yang L, et al. Assessment of thrombin 
generation measured before and after cardiopulmonary bypass surgery and its association with 
postoperative bleeding. J Thromb Haemost. 2011;4:1523–9.  
22.  
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data 
capture (REDCap)-A metadata-driven methodology and workflow process for providing 
translational research informatics support. J Biomed Inf. 2009;42(2):377–81.  
23.  
Nashef S a M, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE 
II. Eur J Cardiothorac Surg. 2012;41:734–44.  
24.  
Kwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 
2014;60:61.  
25.  
Moussa ID, Klein LW, Shah B, Mehran R, Mack MJ, Brilakis ES, et al. Consideration of a 
new definition of clinically relevant myocardial infarction after coronary revascularization: An 

Protocol  
Final Version  
01.09.2017
 
                                                           
34 
 
expert consensus document from the society for cardiovascular angiography and interventions 
(SCAI). J Am Coll Cardiol. 2013;62(17):1563–70.  
26.  
El-Essawi A, Hajek T, Skorpil J, Böning A, Sabol F, Ostrovsky Y, et al. Are minimized 
perfusion circuits the better heart lung machines? Final results of a prospective randomized 
multicentre study. Perfusion. 2011;26(6):470–8.