[Strategy of transfusion in cardiac and aortic surgery].

Current trend in transfusion is a decreasing of the donor's blood use due to possible complications. The article deals with analysis of intraoperative blood loss in different surgeries on the heart and aorta and of a role of blood-saving factors in decreasing of the donor's blood transfusion. We found a correlation between the blood components need and type of surgery and assessed a preoperative provision of autoplasma and intraoperative autohemotransfusion with a blood sampling from the right atrium before the beginning of artificial circulation (Complex use of the blood-saving methods with a prophylactics and treatment of hemostasis disturbances allowed the significantly decreasing of the donor's blood use. 50-70% of patients did not receive components of the donor's blood during cardiac surgery.

[Ways of reducing donor blood components during reconstructive surgery of the heart valves under extracorporeal circulation].

Blood loss and transfusion tactics were analyzed in 131 patients who had undergone correction of one, two, and three cardiac valves under general balanced anesthesia and extracorporeal circulation. The volume of intraoperative blood loss was 869+/-298 ml with the range of 700 to 2000 ml. Packed red cells (PRC) were transfused to 9% of patients; fresh frozen plasma (FFP) in 10%, PRC and FFP were transfused to 17% patients. Donor blood was not used in 63.5% of patients in order to save the patient's blood. It comprised the preoperative storage of autologous plasma in a quantity of 300-700 ml, the modified intraoperative reservation of autologous blood in a volume of 400-1200 ml, and, in 70% of patients, the use of washed autologous red blood cells. The hemostasis protocol included the use of epsilon-aminocapronic acid, aprotinin (trasilol) not more than 2,000,000 KUE, and packed platelets. For adequate heparin neutralization, after administration of the calculated dose of protamine, it was long administered in a dose of 25 mg/hour for 4-5 hours. The developed and introduced comprehensive program for the patient's blood maintenance and blood loss diminution made it possible to avoid transfusing PRC and FFP in more than 60% of patients with a blood loss volume of as high as 1500 ml; and to maintain adequate oxygen balance and hemostasis in the remaining patients.

[Currently available blood saving methods in a patient at cardiac surgery under extracorporeal circulation]. / Sovremennye metody sokhraneniia krovi bol'nogo pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

Different blood saving methods are analyzed in 2000 cardiac surgical patients undergoing coronary and vascular bypass surgery in 1993 to 2000. The basic blood saving methods are as follows: intraoperative autoreinfusion (normovolemic thermodilution), reinfusion of the patient's blood, preoperative autologous plasma donation in combination with aprotinine, aminocapronic acid, etc. An analysis revealed a decrease in homologous blood components intraoperatively. Red blood cell transfusion decreased from 100% in 1993 to 44% in 2000, fresh frozen plasma and platelet transfusions did from 98 to 39% and from 96 to 1%, respectively. Intraoperative homologous blood transfusion could be avoided in 70% of those undergone coronary bypass surgery.

[Implementation of modern principles of blood saving methods at cardiac surgery under extracorporeal circulation]. / Realizatsiia sovremennykh printsipov beskrovnoi khirurgii pri operatsiiakh na serdtse v usloviiakh iskusstvennogo krovoobrashcheniia.

The introduction of principles of bloodless surgery into different areas of practical medicine is favoured by not only risks from donor blood transfusion, but also by the results of the researches dealing with the body's adaptation to acute anemia, with the determination of its allowable limits, and with much experience with bloodless operations used in Jehovah's Witnesses. The present study was undertaken to make a scientific-and-practical assessment of actual own blood funds and their introduction in order to decrease or refuse to use donor blood at cardiac surgery under extracorporeal circulation (EC). A retrospective analysis of hemotransfusion policy in 1993-2001 was conducted in over 2000 patients operated on under EC for coronary heart disease, acquired and congenital cardiac diseases at the Open Cardiac Surgery Department, Russian Surgery Research Center, Russian Academy of Medical Sciences. Own blood saving methods, such as intraoperative autohemotransfusion as two modalities, washed autoerythrocytic reinfusion, autoplasma reinfusion, as well as the use of different pharmaceuticals effective in reducing hemorrhage after EC were evaluated. The introduction of the above own blood saving methods may decrease the use of donor erythrocytes and freshly frozen plasma by 2.6 and 1.8 times, respectively, may completely refuse transfusing thromboplasma, assure adequate hemostasis, reduce the incidence of adverse reactions associated with donor blood transfusion in cardiac surgical patients. A complex use of the developed saving donor blood methods and pharmaceuticals aimed at improving hemostasis allowed donor blood transfusion to be completely refused in more than 70% of patients at aortocoronary bypass surgery under EC.

[Epidemiology and prevention of anaphylactoid reactions in heart surgery patients]. / Epidemiologiia i profilaktika anafilaktoidnykh reaktsii u kardiokhirurgicheskikh bol'nykh.

A retrospective analysis of the incidence, severity, and causes of anaphylactoid reactions (AR) in 1504 cardiosurgical patients operated on at Research Center of Surgery in 1995-1999 showed that AR occurred in 109 (7.4%) patients: 60% during aortocoronary bypass operations, 27.2% during correction of acquired heart diseases, and 12.8% during correction of congenital heart diseases. Skin symptoms predominated in the structure of AR (59.7%); cardiovascular episodes ranked second (38.5%), and the incidence of pulmonary reactions was lowest (1.8%). The causes of AR during anesthesia and surgery were platelet-rich plasma and fresh-frozen plasma (35.3%), antibiotics (12.1%), protamine (12.1%), myorelaxants (9.9%), colloid plasma substitutes (8.8%), dioxidine (3.3%), heparin (2.2%), aprotinin (1.1%), diazepam (2.2%), and other agents (7.6%). A history of AR and repeated interventions are risk factors of AR. The protocol of AR prevention in cardiosurgical patients includes determination of risk factors, selection of the least hazardous agents, strict adherence to the rate of infusion of histamine-releasing drugs, minimum utilization of donor blood components (platelets and plasma), use of H1 and H2 blockers, corticosteroids (celestone) during premedication and operation. Such treatment helped decrease the severity and incidence of AR in cardiosurgical patients to 4.7%.

[Use of corticosteroids betamethasone and prednisolone in the prevention of allergic reactions in patients undergoing heart surgery with artificial blood circulation]. / Primenenie kortikosteroidov--betametazona i prednizolona dlia profilaktiki allergicheskikh reaktsii u kardiokhirurgicheskikh bol'nykh pri operatsiiakh s iskusstvennym krovoobrashcheniem.

The authors discuss measures preventing intraoperative allergic reactions in patients subjected to cardiopulmonary bypass surgery. A retrospective analysis of the incidence of allergic reactions in 1330 patients operated on the heart showed that cardiosurgical patients are liable to anaphylaxis because of intraoperative administrations of numerous drugs (besides anesthetics), specifically, antibiotics, protamine, etc., blood components, solutions. Comparison of the incidence of anaphylactic and anaphylactoid reactions allowed the authors to recommend corticosteroids to be added to anesthesiological protocols with prophylactic purpose. A new corticosteroid betamethasone is more effective than traditional prednisolone in equivalent doses as regards prevention and alleviation of allergic reactions in cardiosurgical patients.

[Clinico-functional correlations of left atrial myocardial excursions in patients with mitral valve defects]. / Kliniko-funktsional'nye korreliatsii kharakteristik ékskursii miokarda levogo predserdiia u bol'nykh porokami mitral'nogo klapana.

The pre- and intraoperative drug maintenance was evaluated in 50 patients with mitral valvular disease and compared with the types of left atrial myocardial excursions. The maintenance with cardiac glycosides and diuretics was greatly different in 3 groups of patients with various types of left atrial myocardial excursions. In patients with Type I excursions the maintenance was minimal, in those with Type III excursions it was maximal, those with Type II excursions, it was intermediate. It is concluded that the functional characteristics of left atrial myocardial excursions may be used as an indicator of cardiac performance.

[Evaluation of the diagnostic effectiveness of the indicators of left atrial myocardial function in intraoperative cardiac weakness in patients with mitral valve defects]. / Otsenka diagnosticheskoi éffektivnosti pokazatelei funktsii miokarda levogo predserdiia v otnoshenii intraoperatsionnoi serdechnoi slabosti u bol'nykh porokami mitral'nogo klapana.

Excursions of the left-atrial myocardium were recorded by tensiometric transducers in patients with mitral valvular disease. The structural features of myocardial excursions were evaluated as symptoms. Myocardial shortening in P-Q interval was considered a negative symptom in relation to heart weakness, shortening in T-Q interval as an indefinite symptom, and shortening in Q-T interval as a positive symptom. Appraisal of the sensitivity and specificity of these symptoms revealed their high diagnostic efficacy.

[Evaluation of right ventricular myocardial excursions in patients with mitral valve stenosis without pulmonary hypertension]. / Otsenka ékskursii miokarda pravogo zheludochka u bol'nykh s mitral'nym stenozom bez legochnoi gipertenzii.

As many as 23 patients with mitral stenosis were examined intraoperatively, by evaluating of intracardiac hemodynamics and right ventricle myocardial excursions. Before mitral stenosis was corrected, 56% of patients had demonstrated myocardial excursion disorders. After the correction the number of patients with myocardial dysfunction halved. The transition of patients belonging to the group with abnormal myocardial excursions to the group with normal excursions depends on the scope of surgical intervention and pharmacological support. After the correction of mitral stenosis cardiogenic and pulmonogenic complications may mostly be seen in the patients' group showing abnormal myocardial excursions. It is concluded that the symptom of abnormal right ventricle myocardial excursions is of prognostic significance with respect to the development of complications in the early postoperative period.

[The status of hemostasis in patients undergoing surgery with artificial circulation]. / O sostoianii gemostaza u bol'nykh, operirovannykh v usloviiakh iskusstvennogo krovoobrashcheniia.

Hemostasis has been assessed in 200 patients during and after cardiopulmonary bypass surgery depending on different protamine sulphate (PS) doses injected for heparin neutralization. It has been demonstrated that the use of 1:1 PS to heparin ratio leads to adequate heparin neutralization and does not cause the appearance of residual heparin in the blood. PS administration at a dose not exceeding that of heparin was accompanied by an intraoperative decrease in platelet count and its more rapid recovery in the early postoperative period.

Effects of hypothermic and pharmacological protection on myocardial metabolism in temporary heart anoxia.

The authors investigated the myocardial metabolism in 11 patients in the course of the an operation (aortic valve prosthesis) under artificial circulation. In 8 patients the myocardium was protected by combined hypothermic and pharmacological cardioplegia, and in 3 patients, solely by hypothermic cardioplegia. It was found that anoxic heart arrest, regardless of the mode of myocardial protection, was accompanied by biochemical shifts in the myocardium (lactacidaemia, hyperphosphataemia, acidosis); the intensity of the shifts, however, was higher, and the durations longer, in the patients protected by hypothermic cardioplegia alone. The authors discuss the usability of the biochemical shifts in the myocardium for the prognosis of the clinical course in the early postperfusion period.