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SECTION 5 Management of cardiopulmonary bypass208

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Table24.2 Summary ofevidence- based practice guidelines

MiECC systems reduce haemodilution, better preserve haematocrit, and reduce postoperative bleeding and the need for packed red blood cell transfusion

Inﬂammatory response is attenuated with use of MiECC Class of recommendation IIA, level of evidence B

MiECC systems reduce cerebral gaseous microembolism and better preserve neurocognitive function Class of recommendation IIA, level of evidence B

MiECC reduces the incidence of postoperative atrial ﬁbrillation Class of recommendation I, level of evidence A

MiECC preserves renal function Class of recommendation I, level of evidence A

MiECC is associated with improved myocardial protection Class of recommendation I, level of evidence A

MiECC has a subclinical protective effect on end- organ function (lung, liver, intestine) caused by improved microvascular organ perfusion

MiECC appears to offer survival beneﬁt in terms of lower 30- day mortality after CABG procedures Class of recommendation IIB, level of evidence B

Source data from 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.

technology in contemporary practice means that few surgical centres have accumulated sucient experience to share it with the scientic community. Concerns have been expressed in the literature regarding safety, ventricular dilatation during perfusion using MiECC, loss of a bloodless eld, and risk of air embolism. However, these reports are anecdotal and theoretical but not supported by large- scale studies; in any case, no fatal or major adverse episodes have been described by any author, which is not the case in other techniques including OPCAB. Nevertheless, MiECC requires a learning curve and a more active intraoperative involvement of both the perfusionist and the anaesthesiologist compared to perfusion with cCPB. Moreover, contemporary perfusion technique necessitates implementation of a perioperative strategy through teamwork; this also mandates a comprehensive multidisciplinary training.

In summary, the concept of MiECC systems initiated important new eorts within science and technology towards a more physiological perfusion in cardiac surgery. Benets of MiECC include reduced haemodilution, less blood transfusion, and improved endorgan protection, and translate into improved clinical outcome. However, in order to draw denite conclusions, large, multicentre, well- designed randomized controlled trials focusing on long- term outcome data are mandatory. us, in 2018, MiECTiS launched Conventional versus Minimally Invasive Extracorporeal Circulation in Patients Undergoing Cardiac Surgery (CoMiCS), a multicentre trial planned to enrol 3500 patients comparing MiECC with cCPB in more than 20 participating centres.

In conclusion, as far as coronary revascularization surgery is concerned, MiECC provides optimal conditions (bloodless eld and arrested heart) to allow the most complete myocardial revascularization while enabling the performance of other concomitant heart surgery.

REFERENCES

1. Serruys PW Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, etal. Percutaneous coronary intervention versus coronary- artery bypass graing for severe coronary artery disease. N Engl J Med. 2009;360:961– 72.

2. Laey JG, Boylan JF, Cheng DC. e systemic inammatory response to cardiac surgery:implications for the anesthesiologist. Anesthesiology. 2002;97:215– 52.

3. Benedetto U, Ng C, Frati G, Biondi- Zoccai G, Vitulli P, Zeinah M, etal. Miniaturized extracorporeal circulation versus o- pump coronary artery bypass graing:a meta- analysis of randomized controlled trials. Int J Surg. 2015;14:96– 104.

4. Hattler B, Messenger JC, Shroyer AL, Collins JF, Haugen SJ, Garcia JA, etal. O- pump coronary artery bypass surgery is associated with worse arterial and saphenous vein gra patency and less eective revascularization:results from the Veterans Aairs Randomized On/ O Bypass (ROOBY) trial. Circulation. 2012;125:2827– 35.

5. Sousa- Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/ EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019;55:4– 90.

6. Beckmann A, Funkat AK, Lewandowski J, Frie M, Ernst M, Hekmat K, etal. German Heart Surgery Report 2015:the annual updated registry of the German Society for oracic and Cardiovascular Surgery. orac Cardiovasc Surg. 2016;64:462– 74.

7. Beholz S, Kessler M, οlke R, Konertz WF. Priming reduced extracorporeal circulation setup (PRECiSe) with the DeltaStream diagonal pump. Artif Organs. 2003;27:1110– 5.

8. Anastasiadis K, Bauer A, Antonitsis P, Gygax E, Schaarschmidt J, Carrel T. Minimal invasive extra- corporeal circulation (MiECC):a revolutionary evolution in perfusion. Interact Cardiovasc orac Surg. 2014;19:541– 2.

9. Immer FF, Ackermann A, Gygax E, Stalder M, Englberger L, Eckstein FS, Tevaearai HT, etal. Minimal extracorporeal circulation is a promising technique for coronary artery bypass graing. Ann orac Surg. 2007;84:1515– 20.

10. Anastasiadis K, Antonitsis P, Argiriadou H, Deliopoulos A, Grosomanidis V, Tossios P. Modular minimally invasive extracorporeal circulation systems; can they become the standard practice for performing cardiac surgery? Perfusion. 2015;30:195– 200.

11. Anastasiadis K, Antonitsis P, Haidich AB, Argiriadou H, Deliopoulos A, Papakonstantinou C. Use of minimal extracorporeal circulation improves outcome aer heart surgery; a systematic review and meta- analysis of randomized controlled trials. Int J Cardiol. 2013;164:158– 69.

12. Anastasiadis K, Murkin J, Antonitsis P, Bauer A, Ranucci M, Gygax E etal. Use of minimal invasive extracorporeal circulation in cardiac surgery:principles, denitions and potential benets. Aposition paper from the Minimal invasive Extra- Corporeal Technologies international Society (MiECTiS). Interact Cardiovasc orac Surg. 2016;22:647– 62.

Class of recommendation I, level of evidence A

Class of recommendation IIA, level of evidence B

24 Minimal invasive extracorporeal circulation forcoronary revascularizationsurgery 209

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13. Kowalewski M, Pawliszak W, Raa GM, Malvindi PG, Kowalkowska ME, Zaborowska K, etal. Safety and ecacy of miniaturized extracorporeal circulation when compared with opump and conventional coronary artery bypass graing:evidence synthesis from a comprehensive Bayesian framework network meta- analysis of 134 randomized controlled trials involving 22,778 patients. Eur J Cardiothorac Surg. 2016;49:1428– 40.

14. Reber D, Brouwer R, Buchwald D, Fritz M, Germing A, Lindstaedt M etal. Beating- heart coronary artery bypass graing with miniaturized cardiopulmonary bypass results in a more complete revascularization when compared to o- pump graing. Artif Organs. 2010;34:179– 84.

15. Puskas JD, Steele M. Would you like some cardiopulmonary bypass with your coronary revascularization? Circulation. 2007;116:1756– 8.

16. Warren OJ, Wallace S, de Wit KL, Vincent C, Darzi AW, Athanasiou T. Variations in the application of various perfusion technologies in Great Britain and Ireland- a national survey. Artif Organs. 2010;34:200– 5.

17. Alevizou A, Dunning J, Park JD. Can a mini bypass circuit improve perfusion in cardiac surgery compared to conventional cardiopulmonary bypass? Interact Cardiovasc orac Surg. 2009;8:457– 66.

18. Anastasiadis K, Antonitsis P, Asteriou C, Argiriadou H, Deliopoulos A, Konstantinou D, etal. Quantication of operational learning in minimal invasive extracorporeal circulation. Artif Organs. 2017;41:628– 36.

19. Anastasiadis K, Antonitsis P, Deliopoulos A, Argiriadou H. A multidisciplinary perioperative strategy for attaining “more physiologic” cardiac surgery. Perfusion. 2017;32:446– 53.

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Cardioplegiastrategies

Constantine L. Athanasuleas and Gerald D. Buckberg

Introduction

Cardioplegia is the intentional temporary cessation of cardiac activity to provide a quiet bloodless eld that facilitates accurate exposure and suture placement during cardiac operations. is chapter reviews the components of a commonly used cardioplegia solution and details a method of cardioplegia delivery that has been used in millions of patients worldwide.

Components ofcardioplegia

e goals of cardioplegia are electrical quiescence, uniform cooling (when hypothermic), and washout of metabolic substances. Cardioplegia solutions vary in their composition (blood or crystalloid in varying ratios), temperature (warm, cold, or tepid), potassium content (high or low), and route of administration (antegrade/ retrograde).

Currently, the most frequently used crystalloid cardioplegia is a modied Bretschneider solution referred to as ‘HTK’ (histidine, tryptophan, keto- glutamate) cardioplegia. HTK contains histidine, a buer for acidosis, keto- glutamate, an amino acid and precursor of nicotinamide dinucleotide phosphate to increase energy production during reperfusion, tryptophan, a membrane stabilizer, and mannitol to decrease oedema formation. Crystalloid cardioplegia shis the oxyhaemoglobin curve leward and it retards adenosine triphosphatase, causing myocardial oedema, activation of platelets, leucocytes, and complement.

Blood cardioplegia contains potassium that promotes rapid electromechanical arrest. Intermittent dosing maintains aerobic metabolism. Blood provides a good buer and scavenges oxygenderived free radicals. Amino acid additives (glutamate and aspartate) replenish energy- depleted ischaemic hearts and are typically infused as a warm solution at the end of ischaemic cross- clamping (‘hot shot’). Blood cardioplegia usually consists of four parts of blood to one part of crystalloid. It maintains oncotic pressure and has advantageous rheological properties. Potassium (20– 40mmol/ L) produces diastolic arrest. Sodium (approximately 150mmol/ L)

is used to minimize sodium inux and intracellular oedema. Citrate phosphate dextrose limits the calcium inux during ischaemia that can damage sarcolemma membranes. Tromethamine (trishydroxymethyl aminomethane or ‘THAM’) is used as a buer to prevent acidosis. THAM diuses into the intracellular space and captures the CO produced by metabolic acidosis. Blood cardioplegia limits reperfusion injury and reverses ischaemia and reperfusion changes in the acutely ischaemic myocardium.

Enriched blood cardioplegia (37°C) contains glutamate and aspartate that replenish key Krebs cycle intermediates that are depleted during ischaemia. Ventricular function is enhanced by delivering this ‘hot shot’ prior to de- clamping of the aorta (Fig. 25.1).

Integratedcardioplegia

cluding the route of delivery (antegrade vs retrograde or both), the mode of delivery (continuous vs intermittent), and temperature (warm vs cold). ‘Integrated cardioplegia’ utilizes each of these and is tailored to the momentary physiological needs of the heart. ere are no time restraints and it works well for fast or slow surgeons. Most importantly, immediate functional recovery aer 6 hours of regional ischaemia can be obtained by controlling both the conditions and composition of the reperfusate.

e ‘Buckberg’ cardioplegia solutions are summarized in Tabl e

25.1. We routinely use two formulations in elective coronary bypass

operations. Bag 1 (induction/ terminal) is a high- potassium, amino acid- enriched solution. It is infused cold aer aortic clamping and infused as a terminal ‘hot- shot’ just before aortic de- clamping to resuscitate the energy- depleted myocardium. Bag 2 (maintenance cardioplegia) is a low- potassium solution infused at 15– 20- minute intervals. Finally, a third cardioplegia (rescue cardioplegia) is given in cardiogenic shock following acute infarction. is is a substrateenriched, hyperosmotic, hypocalcaemic, alkalotic solution containing diltiazem. It is administered as a controlled reperfusion of the infarcted area and results in substantial early recovery of ventricular function.

SECTION 5 Management of cardiopulmonary bypass212

glutamate

(a) (b)

LAP (mmHg)

SWI (gm-m/kg)

LAP (mmHg)

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1.5

1.0

0.5

Control

510

Cold-blood cardioplegia (4 hr)

Normothermic ischemia (45 min)

15 20 25

1.5

1.0

SWI (gm-m/kg)

0.5

510

37°C glutamate + aspartate

37°C

4°C blood

15 20 25

Fig.25.1 (a) Left ventricular function (stroke work index (SWI)), left atrial pressure (LAP) after 4 hours of aortic clamping in normal canine heart

with intermittent cold- blood cardioplegia versus normothermic 45 minutes of clamping. (b)Left ventricular function when jeopardized hearts undergoing 45 minutes of normothermic ischaemia are subjected to 2 more hours of aortic clamping. Note (1)no further improvement when only cold cardioplegic perfusate is given and (2)progressively increased recovery when the cardioplegic solution is supplemented with warm glutamate and aspartate during induction of cardioplegia and reperfusion with intermittent cold doses of blood every 20 minutes of supplemental aortic clamping.

Reproduced from Allen, B.S., Okamoto, F., Buckberg, G.D., Acar, C., Partington, M.T., Bugyi, H.& Leaf, J.1986. Studies of controlled reperfusion after ischemia:Reperfusate composition:IX. Beneﬁts of marked hypocalcemia and diltiazem on regional recovery. J Thorac Cardiovasc Surg, 92, 564– 572 with permission from Elsevier.

Cardioplegia set- up

the vein gra and simultaneously into the coronary sinus. is will be described in the following section.

It is crucial to monitor infusion pressure during cardioplegia delivery because manual estimates of aortic pressure can be misleading. Antegrade pressure should not exceed 70– 80 mmHg to avoid aortic dissection. Retrograde pressure should not exceed 40mmHg. Higher pressure indicates migration of the catheter distally and can lead to rupture. Low pressure indicates misplacement or dislodgement. Perforation of the coronary sinus can usually be directly sutured. Haematomas are oen self- contained aer heparin reversal.

ere are several commercially available cardioplegia delivery systems. One such system is shown in Fig. 25.2. Note the pressure lines for both antegrade and retrograde delivery. Note the added ‘Y’ tubing on the retrograde side for infusion of cardioplegia through

Table25.1 Cardioplegia solutions

Bag 1 Bag 2 Bag 3

Substrate- enhanced Volume (mL) Maintenance Volume (mL) Rescue Volume (mL)

K+ (2mmol/ mL) 16– 20mmol/ L 15 8– 10mmol/ L 10 20– 25mmol/ L 40

THAM (0.3 mol/ L) pH 7.5– 7.7 225 pH 7.6– 7.8 200 pH 7.5– 7.6 225

Citrate– phosphate– dextrose

Aspartate 13mmol/ L 125 13mmol/ L 125

Glutamate 13mmol/ L 125 13mmol/ L 125

Dextrose 50% in water <400 mg/ dL 40 >400 mg/ dL 40

Dextrose 50% in water 380– 400 mOsm 200 none 250

Dextrose 5% in 0.25 normal saline

Diltiazem 300 mcg/ kg body

0.2– 0.4mmol/ L 225 0.5– 0.6mmol/ L 50 0.1– 0.25mmol/ L 225

Cardioplegia forelective coronarybypass

A typical three- vessel coronary bypass using integrated cardioplegia is described, including internal thoracic graing to the anterior descending and two saphenous vein bypasses. Aer sternotomy, the aorta, right atrium, and coronary sinus are cannulated. Cardiopulmonary bypass is instituted with core cooling to 34°C. e aorta is clamped and cold (10°C) bag 1 cardioplegia is infused antegrade at a rate of 300 mL/ min for 2 minutes and retrograde at 200 mL/ min for 2 minutes. Septal temperature is monitored targeted to 10°C or below. If the antegrade pressure exceeds 80mmHg, ow is decreased with a longer infusion.

340– 360 mOsm 550

weight

Fig.25.2 Cardioplegia set- up.

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25 Cardioplegiastrategies 213

Pressure monitor

Vent

Antegrade

Retrograde

Saphenous vein

Following electrical quiescence, the rst anastomosis of vein to the right coronary is performed with the aorta vented to decompress the ventricle. Retrograde cardioplegia provides little protection to the right ventricle because venovenous connections limit access to capillaries. Aer graing and before the suture is tied, cold bag 2 maintenance solution (low potassium) is infused simultaneously retrograde and antegrade through the unattached vein gra. is allows protection of the le ventricle and septum via retrograde ow while protecting the right ventricle via ow through the vein gra. Bag 2 is infused at 200 mL/ min for 1 minute. Air is purged and the suture is tied. During infusion, the distended vein is measured and transected. A4 mm hole is made in the ascending aorta. During the proximal anastomosis, continuous unmodied retrograde cold blood is infused. e only ischaemia time is during the distal anastomoses.

Before tying the proximal anastomosis, the stopcock is turned and bag 2 cardioplegia is infused into the aortic root at 200 mL/ m for 1 minute. Atuberculin needle is used to purge air from the saphenous vein. e rst bypass is now attached proximally and distally. e aorta is again vented as the assistant positions the heart for graing of the next distal. Vein is graed to the marginal for example and bag 2 is infused antegrade through the vein gra as previously and simultaneously retrograde into the coronary sinus. Two sources of opposite ow to the same muscle may seem odd, but drainage is through the ebesian veins. e procedure is repeated as previously if more than two veins are graed. We save the last proximal vein graing until the very end as described later.

Next, the Internal thoracic artery is graed to the anterior descending arterty as the patient and bag 1 cardioplegia (substrate enhanced) are warmed. Aterminal bag 1‘hot shot’ is infused antegrade (200 mL/ min) for 2 minutes and retrograde at 200 mL/ min for 2 minutes. We reserve one proximal anastomosis for the end and this is done during the retrograde infusion. is infusion transitions into plain continuous warm blood as the last proximal is completed. e high- potassium cardioplegia is washed out and the heart begins to

contract. e aortic clamp is le on and the stopcock switched to antegrade warm blood at a ow of 300 mL/ min for 2– 3 minutes until there is vigorous contraction. e clamp is removed and the patient weaned o bypass, usually within 5 minutes despite clamp times over 3 hours. Debrillation is rarely required.

is method has several advantages. ere is no wasted time and the operation ows very smoothly. e only ischaemia is during distal graing. e operative eld is dry at all times. Only two bags of cardioplegia are needed.

Repeat coronary bypass surgery poses several challenges especially when there is a patent internal thoracic artery. Aer limited dissection to expose and cannulate the aorta and atrium, cardiopulmonary bypass is instituted with core cooling to 34°C. It is important not to dissect out the heart until cardioplegic arrest has been established, so as to not compress old gras that can embolize. Temporary occlusion of the internal thoracic artery is done with a so clamp. If this is dangerous, the internal thoracic artery may be le unclamped with repeated episodes of cardioplegia and core temperature reduction to 28°C.

ere are few randomized clinical trials in patients comparing cardioplegic solutions. e meta- analysis of 34 randomized trials by Guru etal. found a signicantly lower incidence of low output syndrome and creatine kinase- MB release with blood versus crystalloid cardioplegia, whereas the incidence of myocardial infarction and death were similar. is meta- analysis was confounded, however, by the fact that the authors were unable to extract data on low output syndrome and creatine kinase- MB from the two largest trials. No dierences in myocardial infarction or mortality were reported. In a review of 18 randomized trials by Jacob etal., ten trials reported some statistically signicant clinical outcomes in favour of blood cardioplegia and ve reported statistically signicant dierences in enzyme release in favour of blood cardioplegia.

ere are few recent surveys of surgeon preference. Asurvey of United Kingdom practice in 2004 found that that 56% of surgeons use cold blood cardioplegia, 14% use warm blood cardioplegia, 14%

SECTION 5 Management of cardiopulmonary bypass214

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use crystalloid cardioplegia, 21% use retrograde infusion, and 16% do not use any cardioplegia. ese analyses compare solutions, not methods of administration, as described herein.

proximal to this anastomosis. Addition of leucocyte ltration is an adjunct that may lead to less inammation markers, less peak creatine kinase, and less catecholamines.

Some surgeons advocate alternatives to blood cardioplegia. A single- centre study compared the HTK solution with repeated tepid cardioplegia in all adult cardiac operations. Propensity- score

Evaluation ofcardioplegiastrategies

matching was used and the authors concluded that the HTK solution was at least as safe as tepid blood cardioplegia. However, cardiac enzymes were not measured nor was the need for inotropic support. Postoperative enzymes have been shown to be related to long- term survival and low output syndrome is associated with a higher complication rate., As Weisel pointed out, no dierence between two cardioplegia strategies is not the same as equivalence or non- inferiority.

Most recently, del Nido cardioplegia used in congenital surgery has been applied in coronary surgery. e solution is based on Plasma- Lyte® A(Baxter Healthcare, Deereld, IL, USA) with added mannitol, magnesium sulphate, sodium bicarbonate, potassium chloride, and lidocaine. It is given as a single dose and good outcomes have been obtained in isolated aortic valve replacement. ere is scarce data regarding its use in coronary surgery and many studies are retrospective. Arecent review of cardioplegia solutions by authors at the Cleveland Clinic supported the use of del Nido cardioplegia in low- risk coronary artery bypass graing, but there was insucient evidence to support its safety in high- risk situations.

Caution must be used in choosing cardioplegia strategies. Enzyme changes rather than clinical outcomes are usually reported. Paradoxical septal motion occurs in as many as 40% of patients aer cardiac surgery, questioning the ecacy of cardioplegia delivery, and can lead to acute right ventricular failure., e septum constitutes approximately 35% of overall ventricular weight and 50% of le ventricular weight so that measuring septal performance should ideally be the yardstick used to compare cardioplegia approaches. We did not observe paradoxical septal motion among 119 patients undergoing a variety of cardiac surgical procedures utilizing the integrated method. Our most recent study evaluated septal function by three- dimensional speckle tracking utilizing the same cold- blood solution comparing antegrade versus antegrade/ retrograde delivery. Only isolated antegrade delivery displayed statistically signicant deterioration of septal function.

Ongoing studies will likely lead to the incorporation of additional cardioprotective methods, such as preconditioning agents, white blood cell lters, oxygen radical scavengers, endothelium- enhancing agents, and molecular factors that will further improve the safety of ischaemic intervals and limit reperfusion damage.

Cardioplegia forevolving myocardial infarction

Acute infarction is sometimes treated with bypass graing. As with percutaneous methods, reperfusion of the occluded artery with blood leads to an acute reperfusion injury and does not restore immediate contractility. Aspecial formulation of cardioplegia has been devised to perfuse the acutely occluded coronary artery and has been extensively reported to prevent or reduce myocardial injury. is ‘rescue cardioplegia’ (Table 25.1, bag 3)is a controlled, substrate- enhanced, low- potassium reperfusion given over 20 minutes to the occluded artery to replenish energy stores. e addition of a calcium channel blocker helps prevent calcium inux.–  Cardiopulmonary bypass is begun and a le ventricular vent placed in the right superior pulmonary vein to decompress the heart. e aorta is clamped and the heart arrested with warm substrate- enhanced cardioplegia (Tabl e

25.1, bag 3)at a ow of 300 mL/ min antegrade for 2 minutes and

200 mL/ min retrograde for 2 minutes. Cold bag 2 is then similarly infused with septal temperature monitoring. e graing proceeds as usual with one major change. Asaphenous vein is graed to the infarct- related artery. is gra is le unattached to the aorta while the hot- shot (bag1) is given antegrade and retrograde as usual. e aortic clamp is removed. e gra to the occluded coronary is then selectively perfused with bag 3 for 20 minutes with the le ventricle vented at a ow of 50 mL/ min. At this point, the last remaining step is to gra the vein gra to the aorta as continuous warm blood is infused retrograde while the aorta is briey clamped. If one chooses to use the internal thoracic artery to the anterior descending artery, it can be graed to the hood of the vein gra and the vein gra ligated

REFERENCES

1. Allen BS, Okamoto F, Buckberg GD, Bugyi HI, Young H, Leaf J, etal. Studies of controlled reperfusion aer ischemia. XV. Immediate functional recovery aer six hours of regional ischemia by careful control of conditions of reperfusion and composition of reperfusate. J orac Cardiovasc Surg. 1986;92:621– 35.

2. Robertson JM, Vinten- Johansen J, Buckberg GD, Rosenkranz ER, Maloney JV. Safety of prolonged aortic clamping with blood cardioplegia. I.Glutamate enrichment in normal hearts. J orac Cardiovasc Surg. 1984;88(3):395– 401.

3. Beyersdorf F. Protection of evolving myocardial infarction and failed PTCA. Ann orac Surg. 1995;60(3):833– 8.

4. Smith RL, Ellman PI, ompson PW, Girotti ME, Mettler BA, Ailawadi G, etal. Do you need to clamp a patent le internal thoracic artery- le anterior descending gra in reoperative cardiac surgery? Ann orac Surg. 2009;87(3):742– 7.

5. Guru V, Omura J, Alghamdi AA, Weisel R, Fremes SE. Is blood superior to crystalloid cardioplegia? Ameta- analysis of randomized clinical trials. Circulation. 2006;114(1 Suppl):I331– 8.

6. Jacob S, Kallikourdis A, Sellke F, Dunning J. Is blood cardioplegia superior to crystalloid cardioplegia? Interact Cardiovasc orac Surg. 2008;7(3):491– 8.

7. Karthik S, Grayson AD, Oo AY, Fabri BM. A survey of current myocardial protection practices during coronary artery bypass graing. Ann R Coll Surg Engl. 2004;86(6):413– 5.

8. Viana FF, Shi WY, Hayward PA, Larobina ME, Liskaser F, Matalanis G. Custodiol versus blood cardioplegia in complex cardiac operations:an Australian experience. Eur J Cardiothorac Surg. 2013;43(3):526– 31.

25 Cardioplegiastrategies 215

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9. Domanski MJ, Mahaey K, Hasselblad V, Brener SJ, Smith PK, Hillis G, etal. Association of myocardial enzyme elevation and survival following coronary artery bypass gra surgery. JAMA. 2011;305(6):585– 91.

10. Rao V, Ivanov J, Weisel RD, Ikonomidis JS, Christakis GT, David TE. Predictors of low cardiac output syndrome aer coronary artery bypass. J orac Cardiovasc Surg. 1996;112(1):38– 51.

11. Weisel RD. Blood or crystalloid cardioplegia:which is better? Eur J Cardiothorac Surg. 2013;43(3):532– 3.

12. Mick SL, Robich MP, Houghtaling PL, Gillinov AM, Soltesz EG, Johnston DR, etal. del Nido versus Buckberg cardioplegia in adult isolated valve surgery. J orac Cardiovasc Surg. 2015;149(2):626– 36.

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https://t.me/medicina_free

Patient blood management strategies incardiacsurgery

Aryeh Shander and Victor A. Ferraris

Burden ofanaemia incardiacsurgery

Anaemia (haemoglobin level <12 g/ dL in women and <13 g/ dL in men) is a common preoperative nding in adult patients undergoing cardiac surgery, with the reported prevalence usually in the range of 25– 50%. e prevalence is usually higher among older patients, those undergoing more complex procedures, patients with heavier burden of disease, and those with longer duration of perioperative hospital stay. Despite its high prevalence and seemingly uncritical nature, anaemia is an important comorbidity that should never be ignored. Anaemia is an independent risk factor for many complications and unfavourable outcomes including renal injury, stroke, ischaemic cardiac events, infections, prolonged ventilatory support, longer hospital stay, and death. Moreover, anaemia is a leading predisposing factor for allogeneic blood transfusions in the perioperative period.

In a study of 2306 patients undergoing non- emergent coronary artery bypass graing (CABG) operations, lower preoperative haematocrit level was an independent predictor of increased risk of major morbidities in subgroups of patients with higher Society for oracic Surgery mortality risk score. Interestingly, transfusion was a signicant independent risk factor for major morbidity among all patients, regardless of their Society for oracic Surgery score categor y. Amulticentre study of 1444 patients undergoing cardiac surgery with cardiopulmonary bypass across 16 hospitals depicted the interaction between anaemia, transfusion, and outcomes. In this study, over one- third of patients were anaemic during the preoperative period, while one- third of patients developed anaemia during surgery and 43% of patients received red blood cell transfusion. Compared with non- anaemic patients, transfused anaemic patients had a 2.6- fold increased risk of developing acute kidney injury. In a meta- analysis of 24 observational studies including around a million surgical patients, preoperative anaemia occurred in 39% of the patients and translated to increased risk of in- hospital mortality, acute kidney injury, and infection. In the subgroup of patients undergoing CABG, anaemic patients had an increased risk of stroke.

Prevalence of anaemia commonly continues to rise as patients spend more days admitted in hospitals, giving rise to what is known

as hospital- acquired anaemia (HAA). HAA can develop in as many as three- quarters of hospitalized non- anaemic patients, while anaemia worsens in prehospital anaemic patients as well. is leaves a majority of patients discharged from the hospital with anaemia, and discharge anaemia persists for a long time and contributes to worsening outcomes in many discharged patient populations including those undergoing cardiac surgery.

Blood transfusion incardiacsurgery

e presence of anaemia is the leading risk factor for transfusion in the perioperative period, increasing the odds ratio of transfusion by as much as vefold. e distribution of blood transfusions in cardiac surgery roughly follows the Pareto’s principle (or the 80– 20 rule) for a complex process:some 80% of blood components are used in around 20% of the patients. is distribution pattern suggests that by focusing on a relatively small percentage of patients, it is possible to achieve signicant reductions in blood utilization. However, what is missing here is the issue of patient outcomes and the fact that the majority of patients undergoing cardiac surgery are transfused— many just receiving 1– 2 units— and a substantial fraction of them suer from the negative consequences of allogeneic blood. On the other hand, a dose– response relationship exists between transfused blood and risks of morbidity and mortality. As the number of transfused red blood cell units increases, the composite risk of morbidity and operative mortality increases.

ese observations do not imply that all allogeneic blood transfusions are always bad. Like any other medical treatments, blood transfusions can help patients when indicated and when their expected benets outweigh their risks. Studies support benets of transfusion in certain high- risk trauma and massive haemorrhage patients. In a study of over 10,000 trauma patients, there was reduced mortality among transfused high- risk patients, while low- risk patients actually had an increased odds ratio of mortality associated with transfusion. Similarly, in a study of over 470,000 surgical patients stratied based on their risk of major morbidity or mortality, blood transfusion was associated with an increased

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