Blood saving techniques in surgery: with special reference to cardiovascular surgery

Homologous transfusion still represents a high-risk procedure due to transfusion reactions or transfusion-related diseases. The search for adequate blood preservation programmes has been introduced particularly in cardiac surgery in order to reduce transfusions during and after cardiac procedures. However, such programmes can also easily be adopted in other surgical disciplines whenever large blood losses are expected. The present review seeks to discuss causes of excessive blood transfusion and to examine various blood preserving techniques that could be used to limit postoperative blood product use. Some guidelines on how to limit excessive use of postoperative blood products also are presented

Combined cardiac surgery in adults, analysis of risk factors and long term results in 127 operations

A total of 127 patient underwent combined coronary artery and valvular operations at our institutions, between 1984 and 1993. Ninety patients underwent coronary artery bypass grafting [CABG] and simultaneous aortic value replacement [AV], 30 patients had CABG and mitral value repair or replacement [MV] and 7 patients had CABG combined with a double-valve operation. An average of 2.7 bypasses were done [range 1-7]. Preoperatively, 97 patients [76%] were categorized in the New York Heart Association [NYHA] functional class 3 or 4. There were 18 emergency operations and 10 reoperative procedures. In 31 patients [24%] the preoperative left ventricular ejection fraction was less than 40%. The overall hospital mortality rate was 11.8% [15/127]. The mortality group [n = 15] was compared to the group of hospital survivors [n = 112] and the following parameters were found to be significant risk factors for perioperatve mortality: age >65 years [p <0.05], insulin-dependent diabetes mellitus [p <0.02], generalized arteriosclerosis [p < 0.01], preoperative NYHA functional classes 3 and 4 [p < 0.02] and double-valve procedures [p < 0.004]. Long-term follow-up revealed a 5-year survival rate of 71.5% for CABG + AV and 62.5% for CABG + MV. The 5-year event-free survival rates were 52.6 and 53.4%, respectively. This study show that, even in high-risk patients, combined valve repair/replacement and CABG surgery can be performed successfully with good, long-term results

Can coronary artery bypass grafting be a treatment of choice in patients with extremely poor left ventricular function?

Advanced ischemic heart disease [IHD] with very low left ventricular ejection fraction [LVEF], pulmonary hypertension [PHT] with or without left ventricular aneurysm [LVA] are criteria for defining end-stage coronary artery disease [ESCAD]. Coronary artery bypass grafting is often denied to these patients.Between January 1,1990 and March 1,1995,145 patients with ESCAD, significant 2 or 3-vessel disease [stenosis > 70%] and LVEF /= 40 mmHg. The overall perioperative mortality was 13.1%. The mortality rate after primary CABG was 12.1%. Low postoperative cardiac output occurred in 41 patients, requiring intraaortic balloon support in 16. Gastrointestinal complications occurred in 7 patients and neurological events in two. Other perioperative complications did not differ. At an average 19 months follow up of 109 hospital survivors, all improved their NYHA class to 1.6 +/- 0.4, mean ergometry tolerance was 93 +/- 32 W and an improved LVEF was achieved, 45.2 +/- 9.1, p < 0.001, without any mortality. All patients improved their MR with at least one grade compared to preoperatively and none has yet required a mitral valve intervention. The 3 year survival rate was 86% and the cardiac event-free survival rate was 79% at 3 years. In Combination of LVEF

Sequential internal mammary artery conduits in coronory artery bypass grafting

The results of sequential internal mammary artery [IMA] grafting in myocardial revascularization, with special emphasis on IMA-related morbidity, have been evaluated over a 2-year period. Between June 1, 1991 and July 1, 1993, 638 patients underwent isolated coronary artery bypass grafting [CABG] at our institution, using the IMA as a conduit. In 541 patients, one or both IMAs were used as a single coronary artery bypass conduit [group 1] and, in the remaining 97 patients; sequential IMA grafting was performed [group 2]. The mean age was 60.1 +/- 9.2 years and 82% of the patients were male. There were 16.6% repeat CABG in group 1 compared to 3.1% in group 2 [p <0.01]. All patients had preoperative angina and 67% were in the Canadian Cardiovascular Society angina class 3 and 4. Other preoperative patient characteristics were similar in both groups. The overall perioperative mortality was 1.9% [12/638]. Twelve patients died in group 1. There were no mortalities in group 2. Nonfatal perioperative myocardial infarction occurred in 10 patients in group 1 [1.6%] and in none in group 2. The incidence of re-exploration for bleeding, sternal wound infections, sternal dehiscence or other perioperative complications was low in both groups. Significant IMA spasm or insufficient IMA flow due to small-caliber vessels occurred in only 1.3% [8/638: 6 patients in group 1 and 2 patients in group 2] [n.s.]. None of the patients with sequential IMA grafts in group 2 had early graft failure [within 30 days postoperatively]. Twelve months postoperatively, 88% [83/94 survivors] of the patients who had received a sequential IMA graft were completely free of angina. Coronary revascularization with sequential IMA graft was found to be safe and effective. Specific IMA problems such as IMA spasm occurred rarely and not more frequently when the IMA was used as sequential graft

Multiorgan leukocyte sequestration during endotoxic shock in sheep

Following injection with indium-111-oxine-labeled leukocytes and Escherichia coli lipopolysaccharide, leukocyte sequestration was observed in the lungs, liver and kidneys in 6 sheep with a corresponding decrease in measured indium-111 oxine leukocytes in the spleen and circulating blood, and a decrease in the leukocyte count in peripheral blood. In the lungs and kidneys, early leukocyte sequestration was followed by a decrease in activity in these organs, with a second phase of continuous leukocyte sequestration beginning 90 min after shock. A steady increase in leukocyte activity was observed in the lungs until the end of the experiment. Leucocyte sequestration may be the pathogenic factor for lung, liver and kidney injury in endotoxin-induced shock