Background
Methods
n | |
---|---|
Hemoglobin < 14 g/l prior to 1998 | 37 |
Emergency Procedures | 36 |
Complex Congenital Heart Disease | 5 |
Cardiogenic Shock | 10 |
Ineffective EPO therapy | 3 |
Sickle cell disease | 1 |
Non correctable hemostasis abnormality (low platelet count) | |
Body Mass Index < 15 | 7 |
Thoraco-abdominal aneurysm | 16 |
Variable | Group A n = 250 | Group B n = 250 |
P
|
---|---|---|---|
1991-1998 | 1998 - 2012 | ||
Blood Volume (ml) | 5 200 +/- 480 | 5000 +/- 610 | >0.05 |
Preoperative HCT (%) | 41+/-2 | 40+/-4 | <0.001 |
Preoperative erythrocyte mass (ml) | 2215+/- 250 | 2010+/-200 | < 0.05 |
Platelets | 220 ± 60 | 180 ± 50 | < 0 .05 |
Body Mass Index | 25 ± 5 | 24 ± 3 | >0.05 |
Age | 51+/-7 | 68+/-5 | <0.001 |
Female gender | 11 | 28 | <0.001 |
Diabetes | 24 | 31 | >0.05 |
Renal Failure | 10% | 10% | >0.05 |
Euroscore | 4.1 +/- 0.8 | 4.8 +/- 1.3 | <0.05 |
Ejection Fraction | 0.45+/-0.2 | 0.40+/-0.1 | <0.001 |
Aortic Clamp Time | 70+/-15 | 65+/-30 | < 0.05 |
Ischemic Time | 55+/-10 | 48+/-15 | >0.05 |
Blood Loss (ml) | 515 ± 310 | 350 ± 140 | <0.001 |
1). Protocol for blood conservation |
a) Preoperative
|
EPO if hemoglobin levels are <14 g/l | |
Iron in all cases | |
Limit the removal of blood in frequency and quantity (use pediatric tubes) | |
Aprotinin (Hammersmith half-protocol) | |
Avoid hematomas following angiography and PCI. | |
b) Perioperative
| |
Retropriming | |
Short CPB circuit. Heparinization 3 mg/kg body weight reversed by equivalent dose of protamine IV | |
CPB conducted in normothermia (minimal temperature drift 36 °C) | |
Warm cardioplegia | |
Cell Saver | |
Minimally invasive surgical techniques | |
Meticulous closure | |
c) Post operative
| |
Reduce blood retrieval in frequency and quantity (use pediatric tubes) | |
Reoperate if blood loss continues at 100 cc for three hrs, or immediately if > 200 cc in one hour. | |
EPO if hematocrit < 24% at time of reoperation | |
2). Protocol of Aprotonin Administration (Hammersmith Half-Protocol) until its withdrawal in 2007 , then aminocaproic acid is used in all cases | 1 million KIU (140 mg) IV at induction of anesthesia, 1 million KIU (140 mg) at completion of CPB and 250,000 KIU (35 mg) IV per hour until skin closure or until a maximum dose of 1 million KIU. |
3). Protocol of Erythropoietin Administration | 300 UI/Kg IV + 500 UI/Kg subcutaneously on admission followed by 500 UI/Kg subcutaneously every second day. |
+ Iron 325 mg PO 3 times a day | |
4). Retropriming | Avoid hemodilution during priming of CPB by passive drainage of blood from venous system |
5). MiniCPB | CPB using centrifugal pump with small volume , in a closed circuit |
Statistical Analysis
Results
GROUP A | GROUP B | |||
---|---|---|---|---|
1991-2003
|
2003-2012
| |||
Intervention |
30 days Mortality
|
30 days Mortality
| ||
Aortic Valve Replacement | 102 | 1 | 63 (4 reoperations) | 1 |
(5 hybrids )* | ||||
Mitral Valve Replacement | 5 | 9 | ||
Double Valve Replacement | 1 | 6 | ||
Mitral Valve-repair | 1 | 21 | ||
CABG | 140 | 2 | 146 (9 reoperations) | |
(25 hybrids)* | ||||
Aortic Dissection | 0 | 2 | ||
ASD repair | 1 | |||
CIA + SINUS VENOSUS | 1 | |||
VSD Repair LV Rupture | 1 | |||
1 |
RESULTS | Group A | Group B |
P
|
---|---|---|---|
30 Day Mortality | 3 | 1 | >0.05 |
Reoperation following bleeding | 4 | 3 | >0.05 |
Acute MI (tropoponine + CPK MB) | 2 | 1 | >0.05 |
Mediastinitis | 0 | 0 | >0.05 |
Stroke | 1 | 0 | >0.05 |
Renal Failure (creatinine level > 2 mg/dL) | 18 | 14 | >0.05 |
Atrial Fibrillation | 20 | 24 | >0.05 |
Ultra-fast Track | 0 | 77 | < 0.001 |
ICU stay (Days) | 3 +/-1 | 4 +/-1 | >0.05 |
Mechanical Ventilation (hrs) | 8 +/- 4 | 2 +/- 1 | < 0.001 |
Hospitalization >7 days | 32 | 18 | < 0.001 |
Procedure | Group A n = 250 | Group B n = 250 |
P
|
---|---|---|---|
1998-2003 | 2003-2012 | ||
Retro-priming | 0 | 250 | <0.001 |
Erythropoietin | 0 | 203 | <0.001 |
Extra-corporal mini-circulation | 0 | 152 | <0.001 |