CARDIO-THORACIC SURGERY TOOLS

Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study. Interact Cardiovasc Thorac Surg. 2009 Apr 2. [Epub ahead of print] Patients in the study group showed lower chest tube drainage (212+/-62 ml vs 420+/-219 ml, p<0.05 ) and lower need for blood products (6.1% vs 40.4%, p<0.05) than patients in the control group. In this randomized study the miniaturized closed circuit extracorporeal circulation MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage as compared to standard CPB.

Coronary artery bypass grafting with a minimized cardiopulmonary bypass circuit: a prospective, randomized trial. J Thorac Cardiovasc Surg. 2009 Feb;137(2):481-5. A minimized cardiopulmonary bypass circuit provides less hemodilution, platelet consumption, chest tube output and lower post-operative blood loss than standard cardiopulmonary bypass. Red blood cell usage was also less. All differences are advantageous

Comparison of transfusion requirements for conventional and miniaturized extracorporeal circuits.Heart Surg Forum. 2008;11(3):E188-92.Hemodilution is a well-recognized phenomenon of cardiopulmonary bypass (CPB). The degree of hemodilution has attendant risks. As the degree of hemodilution increases, red blood cell transfusions may be necessary, and the risks of blood transfusions are becoming very well recognized. Blood-conservation programs are being developed worldwide to establish strategies to reduce transfusions. Miniaturized extracorporeal circuits (MECs) are associated with less hemodilution than conventional CPB circuits. The overall in-hospital transfusion rate for conventional bypass was 63% and 36% for the MEC. The data indicate that use of MECs leads to a lower transfusion rate than in surgeries in which conventional CPB is used.

Protocol Based on Thromboelastograph (TEG) Out-Performs Physician Preference Using Laboratory Coagulation Tests to Guide Blood Replacement During and After Cardiac Surgery: A Pilot Study. Heart Lung Circ. 2008 Dec 29. [Epub ahead of print]. Allogenic blood transfusion may affect clinical outcomes negatively. Up to 20% of blood transfusions in the United States are associated with cardiac surgery and so strategies to conserve usage are of importance. This study compares administration according to physician's choice based on laboratory coagulation tests with application of a strict protocol based on the thromboelastograph (TEG). TEG-based management reduced total product usage by 58.8%. A strict protocol for blood product replacement based on the TEG might be highly effective in reducing usage without impairing short-term outcome.

Perioperative volume replacement in children undergoing cardiac surgery: Albumin versus hydroxyethyl starch 130/0.4. Crit Care Med. 2009 Dec 26. In children undergoing cardiac surgery, 6% HES 130/0.4 may represent an interesting alternative to 4% albumin for intraoperative fluid volume replacement because of its lower cost.

Importance of the time for stopping the combined use of aspirin and clopidogrel in patients undergoing coronary artery by-pass graft surgery

Arch Cardiol Mex. 2008 Apr-Jun;78(2):178-86. Spanish. We studied 49 consecutive patients undergoing first time CABG, and compared two groups: Group A, patients who stopped antiplatelet treatment at least 6 days before surgery, and group B, those who received antiplatelet therapy within 5 days before surgery or did not suspended therapy. The groups were comparable in their demographic characteristics, manifestations of disease, perioperative medication use and the characteristics of surgery. There was a non significant tendency for more cardiovascular complications (primary cardiovascular endpoint) in the group that stopped antiplatelet therapy 6 or more days before surgery the combined use of aspirin and clopidogrel before CABG increases postoperative bleeding and morbidity; there was no definitive difference in the cardiovascular outcome.

Influence of intraoperative fluid volume on cardiopulmonary bypass hematocrit and blood transfusions in coronary artery bypass surgery.

J Extra Corpor Technol. 2008 Jun;40(2):99-108. Patients that received a PRBC transfusion (n = 30) received a significantly higher volume of pre-CPB fluid than nontransfused patients (1800 vs. 1350 mL, p = .0039). These findings suggest that pre-CPB fluid volume can significantly contribute to hemodilutional anemia in cardiac surgery. Optimizing pre-CPB volume may preserve baseline Hct and help limit intraoperative hemodilution

Modified ultrafiltration: role in adult cardiac surgical haemostasis.

J Ayub Med Coll Abbottabad. 2007 Oct-Dec;19(4):49-54. Modified ultrafiltration is a safe procedure which successfully achieves haemoconcentration, lowers blood loss and transfusion requirement after cardiac surgery in adult population.

Transfusion-Free Arterial Switch Operation in a 1.7-kg Premature Neonate Using a New Miniature Cardiopulmonary Bypass System.

J Card Surg. 2008 Jul;23(4):358-360 . 2008 Jul;23(4):358-360. 2008 Jul;23(4):358-360. Case report

Beneficial effects of mini-cardiopulmonary bypass on hemostasis in coronary artery bypass grafting: analysis of inflammatory response and hemodilution.

ASAIO J. 2008 Mar-Apr;54(2):207-9. Mini-CPB attenuated the inflammatory response and hemodilution, resulting in blood conservation in patients undergoing CABG

Hybrid Approach Facilitates Use of a Minimized CPB Circuit and Transfusion Free Surgery in an Extended Norwood Stage II Procedure.

J Card Surg. 2007 Nov-Dec;22(6):508-10. The hybrid approach thereby reduced the complexity of the surgical procedure, facilitated the use of a minimized cardiopulmonary bypass circuit, reduced the degree of hemodilution and blood trauma and resulted in transfusion-free surgery and excellent clinical outcome in an 11 kg child.

Impact of miniaturization of cardiopulmonary bypass circuit on blood transfusion requirement in neonatal open-heart surgery.

ASAIO J. 2007 Nov-Dec;53(6):662-5. Miniaturization of the CPB circuit resulted in decrease in priming volume and subsequent reduction in blood and bicarbonate sodium use. Downsizing the lines had minimal impact on any of the parameters studied, and further efforts should be made to achieve neonatal open-heart surgery without blood transfusion.

Improved coagulation and blood conservation in the golden hours after cardiopulmonary bypass.
J Extra Corpor Technol. 2007 Jun;39(2):103-8. Use of the Hemobag technique for salvaging blood is associated with significant increases in the patient's protein and cellular concentrations and lowered coagulation times in the important, first few golden hours after CPB, and except for one patient, without the addition of expensive and precarious allogeneic blood products.

Acute plateletpheresis and aprotinin reduces the need for blood transfusion following Ross operation.
Interact Cardiovasc Thorac Surg. 2007 Jul 25; [Epub ahead of print] Acute plateletpheresis in combination with low-dose aprotinin significantly reduces the blood product transfusions and blood donor exposures following the Ross operation; the treatment is cost-effective.

Effects of cardiopulmonary bypass circuit reduction and residual volume salvage on allogeneic transfusion requirements in infants undergoing cardiac surgery.
Interact Cardiovasc Thorac Surg. 2007 Jun;6(3):335-9. Epub 2007 Mar 26. Reduction of the circuit volume significantly diminished use of red blood cell concentrates from 1.6 units to 0.8 units (P<0.0001), and fresh frozen plasma from 1.3 units to 0.4 units (P<0.0001). Utilization of the cell salvage product reduced significantly (P=0.023) the postoperative need for homologous blood transfusion. Therefore, both measures proved to be effective in reducing homologous blood transfusion in infant cardiac surgery.

Pediatric cardiac surgery without homologous blood transfusion, using a miniaturized bypass system in infants with lower body weight.
J Thorac Cardiovasc Surg. 2007 Aug;134(2):284-9. It is possible to do complex transfusion-free procedures safely for patients weighing more than 4 kg by using the low-priming volume circuit. The limiting factors of bloodless heart surgery are not preoperative hematocrit and complexity of procedure but the cardiopulmonary bypass time and the patient's body weight

Warfarin cessation before cardiopulmonary bypass: lessons learned from a randomized controlled trial of oral vitamin K.
Ann Thorac Surg. 2007 Jul;84(1):103-8. The cessation of warfarin 6 days preoperatively is sufficient for functional recovery of vitamin K-dependent factors, which undergo significant changes during the operative course. A 5-mg dose of vitamin K with warfarin discontinuation did not enhance recovery of vitamin K-dependent factors and is unnecessary. With the observation that enoxaparin up until the night before surgery resulted in high residual anti-Xa levels in the operating room, our center now administers the last dose of enoxaparin 24 hours before surgery.

Bloodless cardiac surgery: not just possible, but preferable.
Crit Care Nurs Q. 2007 Jul-Sep;30(3):263-70. This article discusses the history of bloodless cardiac surgery, the hazards of transfusion, the benefits of reducing or eliminating transfusion, and strategies to conserve blood.

Minimal cardiopulmonary bypass attenuates neutrophil activation and cytokine release in coronary artery bypass grafting.
J Artif Organs. 2007;10(2):92-5. Mini-CPB appears to attenuate neutrophil activation and cytokine release after coronary bypass surgery and, in addition, has some beneficial effects on blood conservation.

Clinical advantages of using mini-bypass systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo clinical perspective.
Eur J Cardiothorac Surg. 2007 Mar 2; [Epub ahead of print] The adoption of mini-bypass significantly potentially reduces hemodilution, donor blood usage, postoperative bleeding and exposure to GME in routine CABG patients as compared to the use of conventional extracorporeal circulation circuits.