Microplegia vs 4:1 Blood Cardioplegia: Effectiveness and Cost Savings in Complex Cardiac Operations.

BACKGROUND: Microplegia has been studied during isolated coronary artery bypass grafting and valve surgery but not in more complex operations. Objectives of this study were to demonstrate safety and effectiveness of microplegia relative to Buckberg cardioplegia during these operations. METHODS: From January 2012 to January 2017, 242 patients underwent multicomponent operations with simplified microplegia delivered via syringe pump and 10,512 with modified Buckberg cardioplegia. Operations included aortic root, arch, or ascending aorta replacement in 424 (94%) patients, aortic valve surgery in 324 (72%) patients, and concomitant coronary artery bypass grafting in 47 (10%) patients. Outcomes were compared in 226 propensity-matched pairs. RESULTS: There was no difference in median postoperative troponin T between groups after adjusting for aortic clamp time. Microplegia patients received significantly less crystalloid with their cardioplegia (mean 27 ± 8.0 mL/operation vs 735 ± 357 mL/operation; P < .001) and had lower peak intraoperative glucose (196 ± 40 mg/dL vs 248 ± 69 mg/dL; P < .001). Microplegia and Buckberg groups had similar in-hospital mortality (2.7% [n = 6] vs 2.2% [n = 5]; P = .8), stroke (2.2% [n = 5] vs 3.6% [n = 8]; P = .4), renal failure (8% [n = 18] vs 5.8% [n = 13]; P = .4), prolonged ventilation (23% [n = 51] vs 24% [n = 54]; P = .7), median postoperative length of stay (both 8.1 days; P > .9), and median red cell units administered to patients requiring transfusion (4 units vs 3 units; P = .14). The mean cost of cardioplegia per case with microplegia was 1/26th that of Buckberg cardioplegia. CONCLUSIONS: Our simplified microplegia technique offers several advantages over Buckberg cardioplegia without compromising myocardial protection or safety in complex, multicomponent operations with extended aortic clamp times.

Clinical and economic benefits of advanced microplegia delivery system in cardiac surgery: evidence from 250 hospitals.

AIM: Determine the impact of a second generation microplegia delivery system (MPS2) compared with traditional cardioplegia. Materials &  methods: Multivariable difference-in-differences analysis using fixed effects was performed for each outcome: adverse event (AE) composite, total visit cost, medication cost, length of stay (LOS) and  intensive care unit (ICU) days. RESULTS: A 2.25% absolute risk reduction in AE composite was found with MPS2 compared with traditional cardioplegia, which equates to relative risk reduction of 5.25%. Significant reductions in LOS and ICU days (0.1 α level). Per case reduction of US$1231 total visit and US$192 medication costs were found in MPS2 hospitals. CONCLUSION: For hospitals with MPS2, significant reductions were seen in AEs, LOS and ICU days, which lead to reductions in total visit and medication costs.

Myocardial Protection and Financial Considerations of Custodiol Cardioplegia in Minimally Invasive and Open Valve Surgery.

OBJECTIVE: Single-dose antegrade crystalloid cardioplegia with Custodiol-HTK (histidine-tryptophan-ketoglutarate) has been used for many years. Its safety and efficacy were established in experimental and clinical studies. It is beneficial in complex valve surgery because it provides a long period of myocardial protection with a single dose. Thus, valve procedures (minimally invasive or open) can be performed with limited interruption. The aim of this study is to compare the use of Custodiol-HTK cardioplegia with traditional blood cardioplegia in patients undergoing minimally invasive and open valve surgery. METHODS: A single-institution, retrospective case-control review was performed on patients who underwent valve surgery in Lee Memorial Health System at either HealthPark Medical Center or Gulf Coast Medical Center from July 1, 2011, through March 7, 2015. A total of 181 valve cases (aortic or mitral) performed using Custodiol-HTK cardioplegia were compared with 181 cases performed with traditional blood cardioplegia. Each group had an equal distribution of minimally invasive and open valve cases. Right chest thoracotomy or partial sternotomy was performed on minimally invasive valve cases. Demographics, perioperative data, clinical outcomes, and financial data were collected and analyzed. RESULTS: Patient outcomes were superior in the Custodiol-HTK cardioplegia group for blood transfusion, stroke, and hospital readmission within 30 days (P < 0.05). No statistical differences were observed in the other outcomes categories. Hospital charges were reduced on average by $3013 per patient when using Custodiol-HTK cardioplegia. CONCLUSIONS: Use of Custodiol-HTK cardioplegia is safe and cost-effective when compared with traditional repetitive blood cardioplegia in patients undergoing minimally invasive and open valve surgery.

Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations.

BACKGROUND: Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure. METHODS: Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 µg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison. RESULTS: Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 µg/kg (interquartile range [IQR], 16-43 µg/kg) rFVIIa given 51 minutes (42-67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p=0.05; international normalized ratio, 0.8 versus 1.2; p<0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p=0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups. CONCLUSIONS: Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach.

Cost-effectiveness of clinical pathway in coronary artery bypass surgery.

Few studies have been devoted to the exploration of the effect of clinical pathways on coronary artery diseases treated with coronary artery bypass (CAB) surgery. This study was aimed to investigate the cost and effectiveness of the clinical pathway on CAB surgery in a medical center. With a retrospective dataset in 2003-2007, 212 CAB surgery patients were included. Data of the costs and postoperative complication occurrence and length of stays were the focus and patient demographics, surgical risk indicator EuroSCORE, surgical conditions were collected. It revealed that there was differentiation across specified cost items in beating heart CAB surgery patients, but not for heart arrest CAB surgery patients with and without clinical pathways enrolled. In addition, there was no difference in postoperative complication occurrence in CAB surgery patients enrolled into clinical pathways. However, robotic beating heart CAB surgery patients enrolled clinical pathways were shown to have less postoperative ordinary ward stay than those not enrolled clinical pathways. CAB surgery patients' age and surgical risks were related to their postoperative lengths of stay to some extent.

Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study.

OBJECTIVE: Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement. METHODS: Two hundred patients with coronary artery disease were prospectively randomized to (1) on-pump treatment with conventional cardiopulmonary bypass and cardioplegic arrest and (2) off-pump treatment on the beating heart. Postoperative blood loss identified as total chest tube drainage, transfusion requirement, and related costs together with hematologic indices and clotting profiles were analyzed. RESULTS: There was no difference between the groups with respect to preoperative and intraoperative patient variables. The mean ratio of postoperative blood loss and 95% confidence interval between groups was 1.64 and 1.39 to 1.94, respectively, suggesting on average a postoperative blood loss 1.6 times higher in the on-pump group compared with the off-pump group. Seventy-seven patients in the off-pump group required no blood transfusion compared with only 48 in the on-pump group (P <.01). Furthermore, less than 5% of patients in the on-pump group required fresh frozen plasma and platelet transfusion compared with 30% and 25%, respectively, in the on-pump group (both P <.05). Mean transfusion cost per patient was higher in the on-pump compared with that in the off-pump group ($184.8 +/- $35.2 vs $21.47 +/- $6.9, P <.01). CONCLUSIONS: Coronary artery bypass grafting on the beating heart is associated with a significant reduction in postoperative blood loss, transfusion requirement, and transfusion-related cost when compared with conventional revascularization with cardiopulmonary bypass and cardioplegic arrest.

'When more is less'. Reviewing the safety and cost of cardioplegia delivery.

There have been several new cardioplegia delivery systems that have been developed by various manufacturers in the last few years. In this evaluation, the safety and costs associated with the present 4:1 roller pump cardioplegia delivery were compared to the Medtronic Cardioplegia Safety System (CSS). One hundred and five patients participated in a randomized, prospective evaluation. The current cardioplegia delivery system consists of using the 4:1-B MYOtherm XP disposable by Avecor Cardiovascular and a Sarns MDX 7000 roller pump. The Medtronic Cardiotherm disposable cardioplegia unit was used in conjunction with the CSS. The current delivery system will be referred to as group A and the system under evaluation will be referred to as group B. Two varying techniques are employed for cardioplegia delivery and are based on surgeon preference. An equal distribution of techniques was seen in both groups. Results indicated that in group A, a hemoconcentrator was required 60.3% of the time, whereas in group B, a hemoconcentrator was added only 25.0% of the time. The average total cardioplegia delivered in group A was 6,588 cm3 compared to 7,123 cm3 in group B. Although this is insignificant, the greatest difference was seen in the amount of crystalloid given. In group A, the crystalloid portion was 1,317 cm3 compared to only 877 cm3 in group B. There was equal weight gain and hemodilution postop in both groups. Twenty-five incidences of pressurization of the cardioplegia system occurred during the evaluation, with equal distribution in both groups. This evaluation showed that the CSS responded without fail to all pressurization incidences. The Medtronic CSS has incorporated several safety systems for pressurization and air embolism protection, which are programmable and preset by the perfusionist. The Avecor disposable has a pressurization valve that activates at a pressure greater than 600 mmHg in the cardioplegia circuit. The Sarns MDX 7,000 does not incorporate any safety shutoffs. Cost savings were achieved in two areas: hemoconcentrator use and volume of cardioplegia solution required. There was a reduction of 35% in the use of a hemoconcentrator in group B, with more total cardioplegia delivered. The cardioplegia patient cost savings in group B totaled $265.95 per case in the plain cardioplegia group and $315.95 with the amino acid cardioplegia group. The new technology incorporated into the Medtronic CSS demonstrated that it could provide more safety with less cost than the current cardioplegia pump system.

Recycling of cardiopulmonary bypass cannulae: a risk-benefit analysis.

OBJECTIVE: To determine whether recycling of arterial and venous cannulae for cardiopulmonary bypass is associated with an increased risk of infectious complications after open heart surgery. DESIGN: A prospective, risk-benefit analysis. SETTING: A university teaching hospital. PATIENTS: Five hundred and forty patients underwent a variety of non-transplant cardiac operations, which were performed by one surgeon between October 1988 and July 1993. INTERVENTIONS: Standard techniques of open heart surgery were used. Ascending aortic and vena caval cannulae and the multiple perfusion device for administering cardioplegia down saphenous vein bypass grafts were reused an average of 10 to 15 times after sterilization with ethylene oxide after each use. MAIN OUTCOME MEASURES: The postoperative morbidity and mortality and the estimated savings achieved by recycling the cannulae. RESULTS: The operative mortality (total in hospital plus within 30 days of operation) was 2.8% (15 patients). There were no cases of endocarditis; there was only one case of superficial presternal infection and one case of mediastinitis. Gram-negative organisms were cultured from the blood of two patients and gram-positive organisms from the blood of one patient. Only one patient died of an infectious complication. The estimated cost saving during the study period was more than $50,000. CONCLUSIONS: The risk of wound and hematogenous infection after open heart surgery in which recycled cannulae are used is less than 1%. This rate is lower than that quoted in most recent reports. Reuse of heart-lung bypass cannulae may realize substantial cost savings without detriment to the patient.

Myocardial protection during cardiac operations. Decreased morbidity and lower cost with blood cardioplegia and coronary sinus perfusion.

The efficacy of myocardial protection with a single aortic crossclamp and blood cardioplegia was evaluated in 819 consecutive patients stratified for preoperative condition by means of a new clinical risk scoring system. A protocol using either antegrade or antegrade/retrograde blood cardioplegia was compared with antegrade crystalloid cardioplegia in 2582 similar, consecutive, and concurrent patients. In the blood cardioplegia cohort, 97 (11.8%) patients had 129 complications compared with 407 (15.8%) patients and 675 complications in the crystalloid cardioplegia group (p = 0.006). In high-risk patients, combined antegrade/retrograde cardioplegia significantly reduced myocardial infarction, stroke, and respiratory and wound complications. Despite the significantly longer aortic crossclamp time required for blood cardioplegia, patients undergoing crystalloid cardioplegia were 1.7 (95% confidence interval 1.3, 2.1) times more likely to have a morbid event. Time in the intensive care unit, length of hospitalization, and length-of-stay outlier status were significantly decreased in the blood cardioplegia compared with the crystalloid cardioplegia group. The net savings in hospital cost amounted to $2196 per case. When compared separately with crystalloid cardioplegia, combined antegrade/retrograde blood cardioplegia accounted for most of the morbidity reduction by significantly reducing perioperative myocardial infarction, wound complications, and length of stay in patients having reoperations. Antegrade/retrograde blood cardioplegia did not influence 1-year survival or event-free survival, even when risk was considered.