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A comparison study of haemolysis production in three contemporary centrifugal pumps

S Bottrell, M Bennett, S Augustin, C Thuys, B Schultz, A Horton and S Horton
Perfusion published online 9 January 2014
DOI: 10.1177/0267659113509000
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509000
2014

PRF0010.1177/0267659113509000PerfusionBottrell

Original Paper

A comparison study of haemolysis production in

three contemporary centrifugal pumps

Perfusion
0(0) 16
The Author(s) 2014
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DOI: 10.1177/0267659113509000
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S Bottrell,1 M Bennett,1 S Augustin,1 C Thuys,1 B Schultz,1

A Horton1 and S Horton1,2

Abstract
One challenge in providing extracorporeal circulation is to supply optimal flow while minimising adverse affects, such as
haemolysis. To determine if the recent generation constrained vortex pumps with their inherent design improvements
would lead to reduced red cell trauma, we undertook a study comparing three devices. Utilizing a simulated shortterm ventricular assist circuit primed with whole human blood, we examined changes in plasma free haemoglobin values
over a six-day period. The three pumps investigated were the Maquet Rotaflow, the Levitronix PediVAS and the Medos
Deltastream DP3.This study demonstrated that all three pumps produced low levels of haemolysis and are suitable for use
in a clinical environment. The Levitronix PediVAS was significantly less haemolytic than either the Rotaflow (p<0.05) or the
DP3 (p<0.05). There was no significant difference in plasma free haemoglobin between the Rotaflow and the DP3 (p=0.71).
Keywords
centrifugal pump; haemolysis; ECMO; diagonal pump; VAD; hybrid pump; ECLS

Introduction
Blood trauma has been associated with patients requiring
extracorporeal life support (ECLS), with the type of blood
pump utilised contributing to the degree of haemolysis
produced during support.1 It has been shown that centrifugal pumps (CF) possess superior blood handling
capabilities over periods of days to weeks of support when
compared to roller pump based systems.2 This is one reason why CF pumps are gaining wider acceptance in the
ECLS community. However, there is also variance in the
generation of haemolysis in different CF pumps that can
be attributed to a number of design factors.
CF pumps may have several key advantages over roller
pumps when considered for short- to medium-term use
as a ventricular assist device (VAD) or for extracorporeal
membrane oxygenation (ECMO). These advantages
include superior blood handling compared to roller
pumps after only 24 hours of use, there is simpler set up
and implementation, they are smaller, easier to transport
and have improved safety features.2-4
First generation centrifugal pumps were comparatively larger, produced areas of stasis and contained friction points which adversely affected blood components.
With the advent of the current generation of CF pumps,
many of these inherent design drawbacks have been
overcome. It is anticipated this will result in continued
improvements in haemolysis production and patient

management, which is an important consideration when

adopting any new technology.

Methods
To ascertain the red blood cell handling characteristics of
the three devices, we undertook a bench test similar to
our previous study.2
The experimental setup consisted of three pumps: the
Deltastream DP3 diagonal rotary pump (Medos
Medizintechnik AG, Stolberg. Germany), the Rotaflow
shrouded impeller pump (Maquet AG, Hirrlingen,
Germany) and the PediVAS magnetically levitated pump
1Perfusion

Department, Royal Childrens Hospital, Melbourne, Victoria,

Australia
2Department of Paediatrics, Melbourne University, Melbourne, Victoria,
Australia
Corresponding author:
Steve Bottrell
Royal Children's Hospital
50 Flemington Rd
Parkville
Melbourne
Victoria 3052
Australia
Email: steve.bottrell@rch.org.au

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Table 1. Characteristics of centrifugal pumps used in the study.

Flow Range
Speed
Prime (Static)
Connectors
Pulsatility

PediVAS

Rotaflow

Medos DP3

0 - 1.7 L/min
0 - 5500 rpm
14 ml
1/4 inch
No

0 - 9.99 L/min
0 - 5000 rpm
32 ml
3/8 inch
Only with CPB

0 - 8 L/min
100 - 10,000 rpm
16 ml
3/8 inch
Yes

Figure 1. Circuit diagrams of the three centrifugal pumps set

up for the bench test study, with Emtec flowmeter and Lut-ron
manometer.

(Levitronix Technologies LLC, Waltham, Massachusetts.

USA) (Table 1).
An ex vivo circuit, which closely represented our clinical circuit setup used for VAD, was constructed for each
of the three devices. The three circuits (Figure 1) consisted of a standardised, custom-made inch tubing set
(Lovell Surgical, Melbourne, Victoria, Australia).
The circuits were initially primed with 240 ml of
Plasmalyte 148 (Baxter Healthcare, Old Toongabbie, NSW,
Australia) and 33 ml of albumin 20% (CSL Ltd, Parkville,
Victoria, Australia) then recirculated for 10 minutes, as
per our normal practice for priming ECLS circuits.
One fresh unit of citrated whole human bank blood,
mean volume 516 ml (range 510-519 ml) and a mean
age of 4 days (range 3-6 days), was mixed with 1g of ceftazodime and 15 mmol of sodium bicarbonate. Excess
clear prime was removed from the experimental circuits
and 170 ml of the blood mixture was added to give a
total circuit prime volume of 280 ml and a final mean

haemoglobin (Hb) of 100 g/L. After circulating, blood

chemistry analysis was performed to confirm similarity
between circuits at the initiation of the study period and
any residual air in the circuit was removed to minimise
the blood-air interface.
Trial conditions were established using the Rotaflow
as the reference pump, as this is our current clinical
device. These conditions consisted of a sub-atmospheric
preload pressure (-15 to -20 mmHg), an afterload pressure (130-140 mmHg) and a flow rate of 700 ml/min.
The parameters were determined from our patient VAD
database which showed the average flow was 720 ml/
min, the preload pressure was -14 mmHg and the afterload pressure was 130 mmHg. The preload pressure was
achieved by adjusting the height of the reservoir bag relative to the pump head of each circuit and the afterload
pressure was attained by the use of a variable-occlusion
clamp placed on the pump outlet tubing. The individual
pump revolutions were maintained at 2320 revolutions
per minute (rpm) for the Rotaflow, 4900 rpm for the DP3
and 3200 rpm for the PediVAS system for the duration of
the study. Each of the circuits was recalibrated for pressure and flow on a daily basis at the time of blood sampling by adjusting the height of the bag and the
variable-occlusion clamp. Flow for all pumps was determined using a Sono TT Ultrasonic flow monitor (Emtec
Medical Technology, Munich, Germany). The temperature for the study circuits was maintained at a room temperature of 22 degrees Celsius.
Pressure was measured using two medical laboratory
manometers PM-9100HA (Lut-ron Electronic Enterprise
Co. Ltd, Taipei, Taiwan) with an accuracy of 2%.
Once the study parameters were met for flow and inlet
and outlet pressures, an initial blood sample was taken
from each circuit to establish the baseline plasma free
haemoglobin (Plasma Hb) levels and then, at the same
time daily, for six days. A total of five benchtop study
groups were completed. Each study group had three circuits running concurrently. Samples were taken at a
point five centimetres from the pump head outlet. Prior
to the blood sample being taken, 1 ml of blood was taken
and discarded and then 0.5 ml of blood was taken passively into a 2 ml syringe. The blood samples were gently
syringed into a 0.5 ml EDTA blood tube with immediate
analysis after being received by the Royal Childrens
Hospital (RCH) biochemistry laboratory and performed

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Bottrell

on the VITROS 5600 Integrated System (Ortho Clinical

Diagnostics, High Wycombe, Bucks, UK). The VITROS
5600 utilizes the measurement principle of optical
absorbance. Absorbances in the range of 400 800 nm
are automatically read and recorded for each sample and
then multi-variant analysis of the spectral data provides
estimates of haemolysis.
The haemolysis index is then calculated according to:
H = (dA/d( * )aH)

where H = Haemolysis index

dA/d = Derivative absorbance vector
aH = Haemolysis coefficient vector (522 750 nm)
* = Vector dot product (sum of the products of
each vector row)
A limitation of this study was the adjustment of the
afterload pressure by placing variable-occlusion clamps
on the tubing. It has been noted that this method of
obtaining resistance may, in itself, cause increased turbulence and result in greater haemolysis, but this technique
was chosen as we were able to produce a reliable afterload pressure and any contribution to haemolysis should
be consistent across all three circuits.

Statistical Analysis
A one-way analysis of variance (ANOVA) on natural log
transformed data was used on the plasma-free haemoglobin measurements (Stata Quest 12.1, Stata
Corporation, College Station, TX, USA). The MannWhitney U-test was then used to determine at what day
a difference between the non-transformed data of the DP
3, Rotaflow and PediVAS pumps occurred. A probability
value less than 0.05 was considered significant.

Results
Plasma Hb values for the control sample were deducted
from the daily results of the three pump groups. The geometric mean for plasma Hb values was then plotted against
the sample day (Figure 2). It was observed that there was a
trend for the DP3 and Rotaflow to become more haemolytic than the PediVAS pump after two days, with levels
continuing to rise over the course of the trial. For the comparison between the DP3 and Rotaflow pumps only,
ANOVA calculations on log transformed data showed no
statistical difference between the two groups (p=0.71).

Discussion
Haemolysis remains a reliable marker for pump-induced
blood cell trauma. In this study, it was found that the

Figure 2. Natural Log of plasma free Hb vs. days.

Levitronix PediVAS was the least haemolytic of the three

devices bench tested (p<0.05). There was a difference
noted in plasma Hb levels from day two onwards in the
Levitronix PediVAS when compared to the Medos DP3
(p<0.05) and the Maquet Rotaflow pumps (p<0.05).
When comparing the plasma Hb levels of the Rotaflow
and DP3, there was no significant difference (p=0.71).
We analysed the effect of three different devices on the
red blood cells, however, this may not translate to the
handling characteristics on the other formed elements
contained within blood, e.g., platelets and white cells.5
We also note that a statistical difference shown may not
translate into a meaningful clinical difference as there are
variable physiological mechanisms that clear plasma free
Hb.6
The excellent blood handling characteristics of the
PediVAS pump were expected from the growing body of
evidence in the recent literature.7-13 This pump is
designed such that the revolution of the rotor occurs
with less friction and wear. This is controlled by the
motor and results in a stable, entirely levitated impeller
(Figure 3). There are no seals in the device and, combined with the suspended impeller, heat generation is
greatly reduced. The lower heat generation results in less
thermal damage to blood components, causing less haemolysis and a reduced risk of thrombus generation.4,14,15
However, it is also the most expensive of the three devices
tested in this study.
The Rotaflow pump has been used by our unit clinically for the last 13 years for short-term VAD and ECMO
(up to 8 weeks duration). It is a well-engineered, safe and
reliable device that has provided excellent service to our
patient population. The Rotaflow has some significant
design advantages compared to first generation pumps
that have meant lower levels of pump-induced haemolysis and wear, with the clinical benefit of improved circuit
longevity. Inside this pump, the rotor is suspended and
driven by a radial magnetic field that stabilizes the impeller and allows it to be spun on a single blood-flushed

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Figure 3. Cutaway and schematic of the Levitronix PediVAS pump

and drive motor (Images courtesy of Thoratec Corporation).16,17

Figure 4. Rotaflow centrifugal pump. The pump is designed to

exploit the potential of the radial magnetic drive, eliminating a
central shaft and seal by using a blood flushed bearing.19

pivot bearing, as seen in Figure 3. This, in turn, avoids

stagnant zones and reduces areas of high shear and turbulence, giving it a favourable hydraulic efficiency.18
The Deltastream diagonal pump has undergone generational change from an integrated motor and impeller
to a DP2 pump head with separated motor and pump
head to the latest development, the DP3 pump.20 The
Medos DP3 is a diagonal/hybrid rotary pump that
employs a ceramic bearing, magnetic coupling with separate pump head and a prime volume of 16 ml.21
It has been hypothesised by Haneya et al. that the
design of the previous (DP2) diagonal pump may have
led to higher levels of blood trauma.21 This, to some
extent, may be due to the higher rpm required to achieve
a set flow, causing increased shear stress from the bearing. With the newer generation DP3 (Figure 5), this purported issue has been rectified by removing the metal
shaft and sealing ring. The power from the motor is
imparted via a magnetic coupling to the impeller, minimising friction. Our results confirm that the DP3 is at
least as good as the Rotaflow in handling red blood cells.
Rotary pumps can be classified into either centrifugal
or axial pumps. Centrifugal pumps produce higher pressures, but use lower rpm to achieve this. The impeller
blades of centrifugal pumps use the conservation of

angular motion to push the blood off the blades to the

outlet of the pump. Moazami et al. describe this by stating, its rotating element acts as a spinning disk with
blades that can be viewed as a thrower, meaning that the
fluid is captured and thrown tangentially out off the
blade tip to the outlet.23
The axial pumps operate at higher rpm to provide
adequate outlet pressures to achieve flow. The DP3 pump
is a hybrid of these technologies, with faster rpm, but
shorter transit time, allowing for a proposed beneficial
handling of formed elements within blood (Figure 6).
There are many aspects of the pump design process
that can affect the rates of haemolysis and thrombosis.
The predominant cause of extensive haemolysis in CF
blood pumps is thought to be caused by the amount of
shear stress applied and the time of exposure to that
shear stress.25,26 The importance of pump design plays a
major role in this process.
The thickness of the blades, the pitch of the blades, the
number of blades and the distance from the housing of
the pump all have an effect on the hydrodynamic and
haemolytic performance of the centrifugal pump.27-29
The importance of minimising stagnant areas in the
pump and reducing shear stress and friction on the
formed elements will have an impact on the rate of haemolysis.30 Another critical design element is the method
of support for the rotor. Of the three pump heads that we
bench tested, one was totally magnetically suspended
(Levitronix PediVAS) and the other two (Rotaflow &
Deltastream) utilized a small pivot bearing. The magnetic levitation of the rotor allows for the removal of the
mechanical contact point between the rotor and the
housing. Therefore, frictional resistance is kept to a minimum, resulting in greater longevity of the device and
reduced haemolysis, which was supported in our study.
The mechanical pivot bearing offers the advantage of
lower production costs and greater stability over the six
directions of motion for the rotor. However, the additional risk of friction-related heat generation and wear
reduces the longevity of the pump by being a potential
site for fibrin/clot formation.
When considering a blood pump for clinical use,
other design factors to consider include:
1.
2.
3.
4.
5.
6.

Safety and reliability

Operator interface
Portability
Cost
Multiple modes, e.g., pulsatile flow
Data retention

The successful incorporation of these factors is important in the design process as the technology must be
intuitively used by staff from different specialties in an
intensive care setting.

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Bottrell

Figure 5. A diagram of a Medos DP2 (left) and the later version DP3 (right) with the main difference being the removal of the
impeller axis and sealing ring to reduce heat generation and haemolysis. (Images courtesy of Medos Cardiopulmonary Solutions).

and the ability for pulsatile flow. Based on these features

and the DP3s haemolysis profile, the pump warrants further investigation in our clinical setting.
Acknowledgements
The authors would like to thank the following for their
contributions:
Australian Red Cross Blood Service.
Medos Cardiopulmonary Solutions.
Lovell Surgical Supplies, Melbourne, Australia.
Department of Biochemistry, Royal Childrens Hospital,
Melbourne, Australia.
N. Stenning and Co. Pty Ltd
Maquet Getinge Group.
Figure 6. Performance characteristics of axial, diagonal and
centrifugal pumps. It can be seen that greater motion and
pressure per rpm (hydraulic power) is generated as the device
changes design (movement from axial to radial design) while
the operational revolutions increase as the size of the device
decreases. (Adapted from Strmungsmaschinen.24)

Conclusion
In this ex vivo circuit study, based on plasma free haemoglobin, the PediVAS pump was the least haemolytic over
the six days of the trial. There was divergence of plasma
free haemoglobin at day two when compared to the DP3
and Rotaflow. The DP3 and Rotaflow were not significantly different in their generation of haemolysis over the
six days. The DP3 also has several design features which
may be considered advantageous. These include a low
prime volume, user friendly software interface, portability

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.

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