 Hello, my name is Athena and I am a perfusionist in the 401 General Military Hospital of Athens. I would like to thank you for the invitation to participate in this anniversary for the 50 years of the Texas Heart Institute perfusion school. Before I start my presentation for auto transfusion, I would like to spend a few minutes to talk about heart surgery and the history in Greece. The development of cardiac surgery in Greece followed the steps of the pioneers in the US. Professor Lazaridis, who was trained in Heyman Hospital in Philadelphia under the supervision of the famous Charles Bailey, returned to Athens, Greece in 1958 and founded the first program of open heart surgery department in Ipocratio Hospital. The development and evolution of Greek cardiac surgery could be divided in four periods. The first, or SA period 1950 and 1960, characterized by the lack of organization, the experimentation and hesitation from the surgeon side and the reluctance from the patient side to have an operation in Greece. The second, or stabilization period 1960-1970 is the period during which several separate cardiovascular departments were organized and performed the first valve replacement in 1964. The third, or strengthening period 1970-1985 during which Greek surgeons were trained abroad and adapted new methods and techniques of surgical therapy. The first operations of coronary artery by past grafting and aortic aneurysms were performed in 1973-1975. Various purely cardiothoracic centers were founded in Athens and Thessaloniki, the second bigger city in Greece, and cardiac surgery became a routine operation. However, these centers were numerically not enough to cover the demand of patients in need of cardiac surgery. The fourth, or maturity period 1985 till now, it is characterized by the creation of private cardiac surgery departments and the gradual establishment of new university centers at the periphery, which along with the Onassis Cardiac Center eliminated any need for patients to leave the country in order to have a cardiac surgery. In the beginning, the operation of the heart lung machine was left in the hands of enthusiastic but inexperienced volunteers with very poor results. After the failure of the first cases, the heart lung machine, the poor results, perfusionists from abroad were invited to train nursing staff to operate the heart lung machine. The first Greek perfusionists were trained on the job and they also passed their experience in the next generation. Until 2015, there was no official school for perfusionists in Greece. If someone wanted to become a perfusionist, he had to go abroad in a foreign recognized perfusion school or he had to be accepted to shadow next to an experienced perfusionist and to be on the job trained. I consider myself lucky and I will tell you why. In 2013, the new cardiac surgery department in the military hospital of Athens started its operation. There was only one perfusionist at that time and the need to have at least three in the department in order to meet the demands of its full operation. I was then chosen to attend the perfusion program and I was accepted in Texas Heart Institute. I was thrilled and pretty excited to start my new training. I am grateful to all my teachers and my classmates for their guidance and their support. I'm also proud to be a graduate of Texas Heart Institute and celebrate with you all the 50 productive hardworking years of the school. Back to Greece. In 2015, professor Anastasiades, a cardiac surgeon known for his great interest for many evasive extracorporeal circulation created a master's degree program in Aristotelion University of Thessaloniki for perfusionists. So for the first time we have an organized academic school for perfusionists in Greece. In 1992 the Panhellenic Society of Clinical Perfusionists was founded with main goal to make perfusion an officially recognized profession and set the rules and standards for perfusion education, certification and recertification. This year we celebrate the 30 years of society but the goals are still remaining the same. Big steps were made but there are still a lot to be done in order to make perfusion a recognized profession in Greece. Members are 57 active perfusionists from which 24 are European board certified and 3 are American board certified as well. When I was invited to make a presentation about perfusion in Greece, I thought it would be interesting to point out perceptions and opinions of perfusionists, cardiac surgeons anesthesiologists, nurses about cell salvaging. Results of a research like that, it would be interesting to compare respectively with those from abroad. A questionnaire was created with a goal to try to evaluate the level of knowledge of people who are involved in cardiac surgery about cell salvaging. Let's take a look at the results. The questionnaire was given to 80 healthcare professionals and 61 were answered. The first question was in which age group do you belong? Most of the answers were between 45 and 55 years old. Question number two, what is your specialty? In the second question we can see that the most of the answers came from perfusionists and I would like to thank you for that. In the next question we can see how often cell saver is used in practice. From the collected answers, cell saver is used in cases that large amount of blood loss is expected or patient has a low hematogrit or belongs to rare blood. The positive thing is that only two of the 59 answered will never use cell saver. Question number four, how much is the ACT of the product of the cell saver? I have to admit that this is a tricky one. The purpose of this question is to investigate the level of knowledge on the procedure of cell salvage. If people understand that said blood that is aspirated to the cell saver is washed with saline and raged with heparin and only red blood cells are collected with most of the platelets and clotting factors being washed out. That makes the product unable to form blood and not the amount of heparin from the collected answers. We can see that most of the people that think that heparin from the saline used to wash is responsible for the ACT of the product. In this point I would like to filter the answers of what perfusionist answered and what cardiac surgeons from the 32 of the perfusionist answered is that the conclusion is that the majority of the perfusionist know the consistency of the product of the cell saver in contrast to the surgeons who still believe that the product of the cell saver contains heparin proportional to that of the washed saline. With the last question after giving back to the patient large amount of product of cell saver over 500 cc's what would you consider to give an addition? We wanted to point out that good knowledge of the procedure of cell salvage and the components of the final product of the cell saver will lead us to the right management of the patient. Fortunately, most of the healthcare providers seem to understand that when a large amount of blood is processed by cell saver plasma is washed out and all clotting factors as well. In bibliography there is a great interest about the effects of cell salvage in coagulation and a lot of researchers that attempt to discover the best of the blood transfusion. According to the AMSEC and the guidelines of AMSEC for blood management perioperative blood cell should be recovered and re-infused to the patient and blood from the cardiopulmonary bypass circuit at the end of the procedure should be processed by the cell saver and returned to the patient. Additionally some laboratory tests should be used to help us treat the patient appropriately such as INR, PTT, PT, thrombin time thromboelastography, thromboelastometry platelet count and platelet function analysis. According to 2019 European guidelines on cardiopulmonary bypass the best way to deal with shed blood depends on the volume of the shed blood and the characteristics of the patient. For example, smaller volumes of shed blood may be discarded and medium volumes may be processed before returning it. With larger quantities the choice must be made to return shed blood to the patient because large volumes of red blood cells may lead to an excessive loss of plasma resulting in impaired coagulation. The retransfusion of the residual volume of the cardiopulmonary bypass circuit is part of a blood conservation strategy and it can be accomplished in two different ways. First, direct retransfusion without processing and second after processing by centrifugation cell salvage or ultrafiltration only the red blood cells are returned and most of the plasma components are discarded with ultrafiltration however whole blood is concentrated and water soluble components are removed and this is the idea of the new device that we recently started to use in our hospital in the cardiac procedures and it is called HEMOSEP. What is HEMOSEP? It is a cell salvage system that is designed to recover blood loss during cardiac and other surgical procedures providing a concentration of all cell species for transfusion back to the patient by using ultrafiltration It consists of an adult cell concentrator bag a shaker unit a collection bag from the collection of processed blood intraoperative stem and intraoperative kit consisting of a blood collection reservoir and suction and adipodulant lines The HEMOSEP cell concentrator bag is the active processing section of the device and consists of three parts from the blood bag that houses the technology and the blood whilst it is filtered the filter membrane a unique size for structure to control what is able to pass through during filtration means that no cellular components can pass into the super absorbent pad and the super absorbent pad that absorbs all unwanted blood products through the filter membrane turning it into a gel like substance for easy disposal once completed There are a number of researches that investigates clinical evidences to support the use of this new device When we used it we saw that there are a number of disadvantages and the biggest is the high cost of the responsible time it takes 20 minutes to process the blood in order to filtrate it and also the capacity only 500 cc's blood per bag can be processed Despite these disadvantages it is an extra tool that we have to consider and maybe it can find a place in our blood management strategies As a conclusion each patient has its own characteristics BSA, hematocrit, type of surgery cultural and religious beliefs That's why we have to plan individually for every patient our blood management strategy The decision for the best treatment should be made by all members of the team of healthcare providers We have to keep in mind that blood is a living organ and the transfusion is a primary transplant that costs a lot of money Perfusionists, we are the mediators between the patient, the blood and the other specialties That's why our duty is to manage blood with the best available way We can use cell salvage and use all laboratory tests for more focused and evidence-based treatment From the cardiac surgery department of the General Military Hospital of Athens Thank you for your attention