Minimized closed circuit/centrifugal pump extracorporeal circulation: an effective aid in coronary bypass operations in Jehovah's
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《血管的通路杂志》
Department of Cardiovascular Surgery, Heart-Center Brandenburg, Ladeburger Str. 17, 16321 Bernau, Germany
Abstract
Surgical treatment of a Jehovah's Witnesses continues to be a great challenge in cardiac surgery. Different strategies are used to minimize the risk for early mortality, prolonged intensive care unit stay and hospitalization, resulting from anemia. Minimized closed circuit extracorporeal circulations have been shown to reduce adverse effects of conventional CPB. Two patients underwent urgent coronary revascularization for triple-vessel disease. The miniECC (Stckert) is a phosphorylcholine-coated device which integrates the functions of oxygenation, filtration, and pumping in a compact manner with reduced total surface area and priming volume. After a well-tolerated operation the patients showed only minimal red blood cell damage (free hemoglobin 93 mg/l). Hematocrit levels decreasing perioperatively in both patients only moderately (32% and 30%). In these two instances using miniECC we showed a markedly reduced blood cell damage and myocardial trauma. Furthermore, we observed hematocrit levels being higher as compared to standard CABG patients, providing an optimized startpoint for an uneventful postoperative course. MiniECC can be routinely employed and reduces red blood cell damage. Therefore, it can be an effective aid in CABG operations in Jehovah's Witnesses.
Key Words: Minimally closed cardiopulmonary bypass; Jehovah's Witnesses
1. Objectives
Surgical treatment of a Jehovah's Witnesses continues to be a great challenge for every cardiac surgeon, because of the entire avoidance of any kind of blood transfusion. Studies show that cardiovascular operations can, however, be performed safely without blood transfusion [1]. In contrast, blood loss and anemia are considered as independent risk factors for early mortality [1]. In retrospective studies prolonged intensive care unit stay and hospitalization, a higher rate of transient postoperative psychosis, as well as increased susceptibility of the myocardium to ischemic periods is associated with profound anemia, i.e. hemoglobin levels in the vicinity of 4.5 mmol/l [2]. Different strategies are currently used to minimize the occurrence of such scenarios. Specialized pre- and perioperative blood preservation measures are described for these patients including the use of high-dose erythropoietin, aprotinin, intraoperative autologous blood donation, intraoperative cell caving, continuous shed blood reinfusion, and reduction of blood withdrawal for diagnostic purposes [3]. Coronary artery bypass grafting (CABG) is still performed by most surgeons under cardiopulmonary bypass (CPB). CPB, however, is still reported to evoke inflammatory reactions [4] and anemia by red blood cell damage and hemodilution [5,6]. Recently developed minimized closed circuit extracorporeal circulations (miniECC), however, has some evidence to reduce adverse effects of conventional CPB [7,10]. The potential benefit of a closed circuit system in CABG operations for two Jehovah's Witnesses is reported.
2. Case reports
Two patients underwent urgent coronary revascularization for triple-vessel disease without a chance of preoperative autologous blood donation and erythropoetin therapy. Both patients showed an increased risk profile with chronic renal insufficiency and peripheral vascular disease. In both cases the LITA and three vein grafts were used.
The miniECC (ECC.O, Stckert/Sorin) is a device which integrates the functions of oxygenation, filtration, and air elimination in a compact manner in connection with a centrifugal pump (Fig. 1). The tubing set is composed of custom 3/8 polyvinylchloride perfusion circuit coated with phosphorylcholine (Phisio, Sorin, Italy). The total surface area of the circuit is <1.4 m2. The initial priming volume was 850 ml, containing saline, One million IU aprotinin and 5000 I.E. heparin. Antegrade low-volume warm-blood cardioplegia (Calafiore [9]) was administered in all patients. An autotransfusion system was used (Stckert/Sorin).
Body mass index, surface area, and left ventricular function were normal in both patients (male, 68 and 69 years). Operation time was 120 min in both patients. Duration of pump time and aortic cross clamp time were nearly identical (32 min/34 min and 60 min/63 min). In-hospital stay was 13 and 15 days, respectively. Drainage loss was 230 (270 ml) within the first 24 h. Both patients tolerated the surgical procedure well and exhibited an uneventful course without significant complications. Creatinkinase – Mb – levels indicated minor intraoperative myocardial damage with 0.01 (0.03) μmol/l at the end of the operation and 0.38 (0.48) μmol/l at first postoperative day.
Hemoglobin levels moderately decreased in both patients during the surgical procedure to 6.5 and 6.3 mmol/l and remained stable over the entire postoperative time course. Hematocrit values at the end of the operation were 32% and 30%, respectively. Free hemoglobin levels increased during surgery only transiently between 89 and 93 mg/l. At hospital discharge, hematocrit values had increased to 33% in both patients and hemoglobin levels reached 7 and 7.1 mmol/l, respectively. In both patients renal complications, transient psychosis, tachyarrhytmias, and other major complications remained absent.
3. Comment
Different strategies to reduce anemia during CABG have already been investigated [1–3]. We could show that the use of the MiniECC system resulted in a markedly reduced blood cell damage, a lower degree of tissue trauma as well as a reduced alteration of the coagulation-cascade when compared with patients operated upon using standard CPB [7]. In these two instances, we observed hematocrit levels of 30% or more at the end of the surgical procedure being significantly higher as compared to standard CABG patients of our department as well as in other study groups [7,8]. This provides an optimized startpoint for an uneventful postoperative course. Nevertheless, an experienced surgeon appears to be mandatory to make most use of this advantage. Furthermore, all appropriate measures to enhance erythropoesis may be implemented to avoid being confronted with a medical indication for blood unit substitution during the postoperative course.
4. Conclusions
Progressive advances in perfusion technology and perioperative supportive management have made it possible for Jehovah's Witnesses to undergo open cardiac operations with remarkable safety. MiniECC of the modern generation are effective in CABG operations in these patients because it can be routinely employed and appears to be safe. Perioperative reduction of red blood cell trauma is of potential value.
References
Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion. J Am Med Assoc 1977; 238:1256–1258.
Herzchirurgie in Zeugen Jehovas. Dissertation WFW Uni Münster 2005 Dakkak AR.
Rosengart TK, Helm RE, DeBois WJ, Garcia N, Krieger KH, Isom OW. Open heart operations without transfusion using a multimodality blood conservation strategy in 50 Jehovah's Witness patients: implications for a ‘bloodless’ surgical technique. J Am Coll Surg 1997; 184:618–629.
Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth DE, Pacifico AD. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983; 86:845–857.
Dial S, Delabays E, Albert M, Gonzalez A, Camarda J, Law A, Menzies D. Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg Sep 2005; 130:654–661.
Chenoweth DE, Cooper SW, Hugli TE, Stewart RW, Blackstone EH, Kirklin JW. Complement activation during cardiopulmonary bypass: evidence for generation of C3a and C5a anaphylatoxins. New Eng J Med Feb 26, 1981; 304:497–503.
Just SS, Müller T, Hartrumpf M, Albes JM. First experience with closed circuit/centrifugal pump extracorporeal circulation: cellular trauma, coagulatory, and inflammatory response. Interact Cardiovasc Thorac Surg 2006; 5:646–648.
Vaislic C, Bical O, Farge C, Gaillard D, Ponzio O, Ollivier Y, Abdelmoumen Y, Robine B, Souffrant G, Bouharaoua T. Totally minimized extracorporeal circulation: an important benefit for coronary artery bypass grafting in Jehovah's Witnesses. Heart Surg Forum 2003; 6:307–310.
Just S, Kupferschmidt M, Müller T, Schubel B. Calafiore- vs. Buckberg- Blutkardioplegie in der elektiven koronaren Bypasschirurgie. Kardiotechnik 2002; 11:72–74.
Albes JM, Sthr IM, Kaluza M, Siegemund A, Schmidt D, Vollandt R, Wahlers T. Physiological coagulation can bemaintained in extracorporeal circulation by means of shed blood separation and coating. J Thorac Cardiovasc Surg 2001; 126:1504–1512.(Sren S. Just, Torsten Müller and Johanne)
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Surgical treatment of a Jehovah's Witnesses continues to be a great challenge in cardiac surgery. Different strategies are used to minimize the risk for early mortality, prolonged intensive care unit stay and hospitalization, resulting from anemia. Minimized closed circuit extracorporeal circulations have been shown to reduce adverse effects of conventional CPB. Two patients underwent urgent coronary revascularization for triple-vessel disease. The miniECC (Stckert) is a phosphorylcholine-coated device which integrates the functions of oxygenation, filtration, and pumping in a compact manner with reduced total surface area and priming volume. After a well-tolerated operation the patients showed only minimal red blood cell damage (free hemoglobin 93 mg/l). Hematocrit levels decreasing perioperatively in both patients only moderately (32% and 30%). In these two instances using miniECC we showed a markedly reduced blood cell damage and myocardial trauma. Furthermore, we observed hematocrit levels being higher as compared to standard CABG patients, providing an optimized startpoint for an uneventful postoperative course. MiniECC can be routinely employed and reduces red blood cell damage. Therefore, it can be an effective aid in CABG operations in Jehovah's Witnesses.
Key Words: Minimally closed cardiopulmonary bypass; Jehovah's Witnesses
1. Objectives
Surgical treatment of a Jehovah's Witnesses continues to be a great challenge for every cardiac surgeon, because of the entire avoidance of any kind of blood transfusion. Studies show that cardiovascular operations can, however, be performed safely without blood transfusion [1]. In contrast, blood loss and anemia are considered as independent risk factors for early mortality [1]. In retrospective studies prolonged intensive care unit stay and hospitalization, a higher rate of transient postoperative psychosis, as well as increased susceptibility of the myocardium to ischemic periods is associated with profound anemia, i.e. hemoglobin levels in the vicinity of 4.5 mmol/l [2]. Different strategies are currently used to minimize the occurrence of such scenarios. Specialized pre- and perioperative blood preservation measures are described for these patients including the use of high-dose erythropoietin, aprotinin, intraoperative autologous blood donation, intraoperative cell caving, continuous shed blood reinfusion, and reduction of blood withdrawal for diagnostic purposes [3]. Coronary artery bypass grafting (CABG) is still performed by most surgeons under cardiopulmonary bypass (CPB). CPB, however, is still reported to evoke inflammatory reactions [4] and anemia by red blood cell damage and hemodilution [5,6]. Recently developed minimized closed circuit extracorporeal circulations (miniECC), however, has some evidence to reduce adverse effects of conventional CPB [7,10]. The potential benefit of a closed circuit system in CABG operations for two Jehovah's Witnesses is reported.
2. Case reports
Two patients underwent urgent coronary revascularization for triple-vessel disease without a chance of preoperative autologous blood donation and erythropoetin therapy. Both patients showed an increased risk profile with chronic renal insufficiency and peripheral vascular disease. In both cases the LITA and three vein grafts were used.
The miniECC (ECC.O, Stckert/Sorin) is a device which integrates the functions of oxygenation, filtration, and air elimination in a compact manner in connection with a centrifugal pump (Fig. 1). The tubing set is composed of custom 3/8 polyvinylchloride perfusion circuit coated with phosphorylcholine (Phisio, Sorin, Italy). The total surface area of the circuit is <1.4 m2. The initial priming volume was 850 ml, containing saline, One million IU aprotinin and 5000 I.E. heparin. Antegrade low-volume warm-blood cardioplegia (Calafiore [9]) was administered in all patients. An autotransfusion system was used (Stckert/Sorin).
Body mass index, surface area, and left ventricular function were normal in both patients (male, 68 and 69 years). Operation time was 120 min in both patients. Duration of pump time and aortic cross clamp time were nearly identical (32 min/34 min and 60 min/63 min). In-hospital stay was 13 and 15 days, respectively. Drainage loss was 230 (270 ml) within the first 24 h. Both patients tolerated the surgical procedure well and exhibited an uneventful course without significant complications. Creatinkinase – Mb – levels indicated minor intraoperative myocardial damage with 0.01 (0.03) μmol/l at the end of the operation and 0.38 (0.48) μmol/l at first postoperative day.
Hemoglobin levels moderately decreased in both patients during the surgical procedure to 6.5 and 6.3 mmol/l and remained stable over the entire postoperative time course. Hematocrit values at the end of the operation were 32% and 30%, respectively. Free hemoglobin levels increased during surgery only transiently between 89 and 93 mg/l. At hospital discharge, hematocrit values had increased to 33% in both patients and hemoglobin levels reached 7 and 7.1 mmol/l, respectively. In both patients renal complications, transient psychosis, tachyarrhytmias, and other major complications remained absent.
3. Comment
Different strategies to reduce anemia during CABG have already been investigated [1–3]. We could show that the use of the MiniECC system resulted in a markedly reduced blood cell damage, a lower degree of tissue trauma as well as a reduced alteration of the coagulation-cascade when compared with patients operated upon using standard CPB [7]. In these two instances, we observed hematocrit levels of 30% or more at the end of the surgical procedure being significantly higher as compared to standard CABG patients of our department as well as in other study groups [7,8]. This provides an optimized startpoint for an uneventful postoperative course. Nevertheless, an experienced surgeon appears to be mandatory to make most use of this advantage. Furthermore, all appropriate measures to enhance erythropoesis may be implemented to avoid being confronted with a medical indication for blood unit substitution during the postoperative course.
4. Conclusions
Progressive advances in perfusion technology and perioperative supportive management have made it possible for Jehovah's Witnesses to undergo open cardiac operations with remarkable safety. MiniECC of the modern generation are effective in CABG operations in these patients because it can be routinely employed and appears to be safe. Perioperative reduction of red blood cell trauma is of potential value.
References
Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion. J Am Med Assoc 1977; 238:1256–1258.
Herzchirurgie in Zeugen Jehovas. Dissertation WFW Uni Münster 2005 Dakkak AR.
Rosengart TK, Helm RE, DeBois WJ, Garcia N, Krieger KH, Isom OW. Open heart operations without transfusion using a multimodality blood conservation strategy in 50 Jehovah's Witness patients: implications for a ‘bloodless’ surgical technique. J Am Coll Surg 1997; 184:618–629.
Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth DE, Pacifico AD. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983; 86:845–857.
Dial S, Delabays E, Albert M, Gonzalez A, Camarda J, Law A, Menzies D. Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg Sep 2005; 130:654–661.
Chenoweth DE, Cooper SW, Hugli TE, Stewart RW, Blackstone EH, Kirklin JW. Complement activation during cardiopulmonary bypass: evidence for generation of C3a and C5a anaphylatoxins. New Eng J Med Feb 26, 1981; 304:497–503.
Just SS, Müller T, Hartrumpf M, Albes JM. First experience with closed circuit/centrifugal pump extracorporeal circulation: cellular trauma, coagulatory, and inflammatory response. Interact Cardiovasc Thorac Surg 2006; 5:646–648.
Vaislic C, Bical O, Farge C, Gaillard D, Ponzio O, Ollivier Y, Abdelmoumen Y, Robine B, Souffrant G, Bouharaoua T. Totally minimized extracorporeal circulation: an important benefit for coronary artery bypass grafting in Jehovah's Witnesses. Heart Surg Forum 2003; 6:307–310.
Just S, Kupferschmidt M, Müller T, Schubel B. Calafiore- vs. Buckberg- Blutkardioplegie in der elektiven koronaren Bypasschirurgie. Kardiotechnik 2002; 11:72–74.
Albes JM, Sthr IM, Kaluza M, Siegemund A, Schmidt D, Vollandt R, Wahlers T. Physiological coagulation can bemaintained in extracorporeal circulation by means of shed blood separation and coating. J Thorac Cardiovasc Surg 2001; 126:1504–1512.(Sren S. Just, Torsten Müller and Johanne)
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