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The main purpose of this study was to estimate the costs and savings related to a consistent autotransfusion programme. More than 8,000,000 ml of autologous blood or blood-containing fluid were collected from 3,637 consecutive patients undergoing coronary artery bypass and returned to the patients during and after the operation. Economic analyses revealed a price of NOK 13 million (approximately 2 million USD) for this amount of autologous blood, or NOK 3,500 (600 USD) per patient. In the present series the need for bank blood or blood products was modest, since 69 patients (1.9%) received packed red cells, with or without plasma, 76 patients (2.1%) were given plasma transfusions only, and 11 patients (0.3%) received platelets. Thus, 95.7% of the patients were not exposed to any homologous blood products during the stay in hospital. Absence of morbidity related to the low homologous blood transfusion rate was assumed to save costs substantially, although this saving was difficult to calculate in terms of currency. Post-operative complications were few, and the total in-hospital mortality rate was 0.4%.

Background: The concepts of minimally invasive coronary artery bypass grafting have gained increasing attention and interest from cardiac surgeons. Operations through small incisions are mostly applied to patients with less extensive coronary disease, mostly single-vessel disease. The aim of this study was to identify a baseline level of conventional coronary bypass grafting for this group of patients, particularly with regard to surgical complications and immediate results., Methods: Of 3,637 consecutive patients undergoing coronary artery bypass grafting during the period 1989 to 1995, 99 patients (2.7%) were identified to have single-vessel disease. The preoperative and hospital data of this subset of patients were analyzed., Results: The left internal mammary artery was grafted in 96% of the patients, either as single graft to the left anterior descending artery or sequentially to the left anterior descending artery and a diagonal branch. Additional vein grafts were placed in 36 patients, and the mean number of distal anastomoses was 1.6 +/- 0.6. Mean ischemic time and cardiopulmonary bypass time were 15.3 +/- 9.6 minutes and 29.0 +/- 12.5 minutes, respectively. The patients were weaned from the ventilator 1.5 +/- 0.8 hours postoperatively, and all patients were out of bed the morning after the operation. No patients required homologous blood or plasma transfusions. The morbidity rate was low, and all patients survived., Conclusions: For this highly selected group of patients, coronary artery bypass grafting based on median sternotomy, cardiopulmonary bypass, and cardioplegic arrest carries a very high rate of immediate success. Such data may be useful as a baseline when considering the costs and benefits of new surgical procedures.

Complete heparin-coated extracorporeal circuits, including cardiotomy reservoir, have recently become available for routine cardiac surgery. The effects on complement and granulocyte activation using a heparin-coated circuit in combination with reduced systemic heparinization (activated clotting time (ACT) > 250 s) were studied in 33 patients undergoing elective first time myocardial revascularization. The patients were prospectively randomized either to a heparin-coated group (Group H, n = 17), or to a control group (Group C, n = 16) treated with an identical uncoated circuit and full heparin dose (ACT > 480 s). During cardiopulmonary bypass (CPB) the C3 activation products C3b, iC3b, and C3c (C3bc) and the terminal SC5b-9 complement complex (TCC) increased markedly in both groups compared to baseline, but to a much lesser extent in the heparin-coated group. The maximal increase of C3bc during the operation was a median of 28 arbitrary units (AU)/ml in the heparin-coated group, compared to 45 AU/ml in the control group (P = 0.01). Similarly, in Group H the maximal increase of TCC was significantly lower (median 0.8 AU/ml) than the levels recognized in Group C (median 1.9 AU/ml) (P < 0.0001). The release of the granulocyte activation enzymes lactoferrin and myeloperoxidase also increased during CPB in both groups compared to baseline level. The maximal increase of lactoferrin concentration was a median of 229 micrograms/l in Group H and significantly lower than 647 micrograms/l in the control group (P = 0.0002). As for myeloperoxidase, there were no significant intergroup differences. In conclusion, a complete heparin-coated circuit and low systemic heparinization for CPB in coronary artery surgery were associated with reduced activation of the complement system and less release of lactoferrin. The results indicate improved biocompatibility of this option for extracorporeal circulation.

Complement and granulocyte activation were studied in cardiopulmonary bypass circuits completely coated with either end-attached covalent-bonded heparin, the Carmeda BioActive Surface, or with the Duraflo II bonded heparin, in combination with reduced systemic heparinization (activated clotting time > 250 seconds). The control groups were perfused with uncoated circuits and full heparin dose (activated clotting time > 480 seconds). Altogether 67 patients undergoing elective first-time myocardial revascularization were investigated, having extracorporeal perfusion with a Duraflo II coated circuit (n = 17), an identical but uncoated circuit (n = 17), a Carmeda coated circuit (n = 17), or an equivalent uncoated circuit (n = 16). During cardiopulmonary bypass, the C3 activation products C3b, iC3b, and C3c (C3bc) and the terminal SC5b-9 complemented complex increased markedly in all four groups compared with baseline, but significantly less in the two coated groups than in their control groups. Additionally, a significantly lower concentration of C3bc was observed in the Carmeda coated group, with maximal increase of median 28 AU/ml compared with 50 AU/ml in the Duraflo II coated group (p = 0.003). Similarly, in the Carmeda coated group, the maximal increase of terminal complement complex was considerably lower (0.8 AU/ml) than the levels recognized in the Duraflo II coated group (2.4 AU/ml) (p < 0.001). The release of the granulocyte activation myeloperoxidase and lactoferrin increased from the beginning of the operation, with peak levels at the end of bypass. A significant reduction of lactoferrin release was recognized when comparing the coated groups with the control groups. The difference between the two coated groups (Carmeda 228 micrograms/L; Duraflo II 332 micrograms/L; p = 0.05) was marginally significant. For myeloperoxidase, no significant differences were observed between the coated and uncoated groups. In conclusion, both types of heparin-coated circuits reduced complement activation and release of lactoferrin, but the Carmeda circuit proved to be more effective than the Duraflo II equipment.

Because much interest has been focused on blood conservation using different drugs and complicated blood cell processing devices, we analyzed our results with the use of a non-pharmacologic, simple and inexpensive program for blood salvage in 2326 patients undergoing myocardial revascularization. The material was divided into two groups: patients undergoing a primary coronary bypass operation (Group P, n = 2298) and a smaller subset of patients undergoing repeat coronary bypass operation (Group R, n = 28). At least one internal mammary artery was grafted in 99% of the patients, with supplemental saphenous vein grafts. Intraoperatively, autologous heparinized blood was removed before bypass and retransfused at the conclusion of extracorporeal circulation. The volume remaining in the extracorporeal circuit was returned without cell processing or hemofiltration. Autotransfusion of the shed mediastinal blood was continued hourly up to 18 h after surgery in all patients. The mean postoperative mediastinal drainage in group R was 543 +/- 218 ml, compared to 703 +/- 340 ml in Group P (P = 0.01). In Group R, 1 patient (3.6%) received packed red cells and no patients were given other homologous blood products, compared to 33 patients (1.4%) given red cells and 35 patients (1.5%) given plasma transfusion in Group P (NS). Thus, in total, 2257 patients (97.0%) were not exposed to any homologous blood products during hospitalization. Total hemoglobin loss was significantly higher in Group R, resulting in a mean hemoglobin concentration at discharge of 109 +/- 13 g/l, compared to 121 +/- 14 g/l in Group P (P = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

The contribution of fibrinolysis to postoperative bleeding after cardiopulmonary bypass led to routine use of tranexamic acid, a potent antifibrinolytic drug, for a period of time. Two hundred patients undergoing elective coronary artery bypass operations were studied, one group of 100 patients given tranexamic acid (40 mg/kg) (group I) after bypass and one subsequent group of 100 patients (group II) serving as a control group. All patients were treated by the same team, and the groups were comparable in all major clinical parameters. The mean mediastinal drainage in group I was 565 +/- 239 ml versus 656 +/- 257 ml in group II. Univariate and multivariate analysis revealed statistical significance (p = 0.02) when corrected for body surface area. However, applying a consistent blood conservation protocol, including removal of autologous blood before bypass for retransfusion after bypass, returning of all oxygenator and tubing contents to the patients, and autotransfusion of the mediastinal shed blood up to 18 hours postoperatively, resulted in nearly identical hemoglobin concentration at discharge (119 +/- 14 gm/L in group I and 121 +/- 14 gm/L in group II). The prevalence of postoperative myocardial infarction included five patients in group I compared with one patient in group II. Although not statistically significant (p = 0.2), the difference is of concern. Tranexamic acid has a beneficial effect on reducing postoperative bleeding after coronary artery bypass operations. The routine use of the drug is not recommended, however, because its effect is a weak one, and it may be of potential hazard by precipitating thrombosis and eventual myocardial infarction.

With use of a nonpharmacological, simple, and inexpensive program for blood conservation, 500 consecutive patients underwent elective coronary artery bypass grafting without need of homologous red cell transfusions in 493 (98.6%). At least one internal mammary artery was grafted in all but 1 patient, with supplemental saphenous vein grafts. Intraoperatively, autologous heparinized blood was removed before bypass and retransfused at the conclusion of extracorporeal circulation. The volume remaining in the oxygenator and tubing set was returned without cell processing or hemofiltration. Using the hard-shell cardiotomy reservoir from the heart-lung machine, autotransfusion of the shed mediastinal blood was continued hourly up to 18 hours after operation. The mean postoperative mediastinal blood loss was 643 +/- 354 mL, whereas 624 +/- 296 mL was autotransfused. Thirteen patients (2.6%) needed reexploration for bleeding, of whom 7 (7/500, 1.4%) received homologous blood. No other patients required red cell transfusions. In addition, 9 patients were given a mean of 2.6 units of fresh frozen plasma because of suspected coagulopathy. No platelets were transfused, and no cryoprecipitate therapy was undertaken. Thus, in total, 484 patients (96.8%) were not exposed to any homologous blood products during the hospital stay. At discharge, the mean hemoglobin concentration was 121 +/- 14 g/L (12.1 +/- 1.4 g/dL) and the hematocrit, 0.36 +/- 0.04. Postoperative complications were few. There was one in-hospital death (0.2%).

Restriction of donor blood transfusions in cardiac surgery should reduce risks of infective contamination and antigenicity. We report a systemic, simple and inexpensive blood conservation program used for 121 consecutive patients who underwent elective coronary artery bypass surgery without need for homologous blood transfusion. The left internal mammary artery was grafted in all cases, in addition to saphenous vein grafts. Autologous, heparinized blood was removed intraoperatively, pre-bypass, and returned to the patient at conclusion of the extracorporeal circulation. The volume remaining in the oxygenator and the tubing set was returned without cell processing or hemofiltration. Using the hard-shell cardiotomy reservoir from the heart-lung machine, autotransfusion of the shed mediastinal blood was continued hourly up to 18 hours after surgery. The mean postoperative mediastinal bleeding was 551 +/- 206 ml, of which 505 +/- 218 ml was autotransfused. No re-exploration for bleeding was required and no homologous red-cell transfusions were given. Five patients each received 1-2 units of fresh frozen plasma because of prolonged bleeding time. Morbidity was low and mortality nil. At discharge the mean hemoglobin was 12.0 +/- 1.4 g/dl and the hematocrit 36.0 +/- 4.2%.

Blood conservation in open heart surgery has become mandatory in order to reduce the risk of viral contamination, and because of limited resources. We have performed 100 consecutive coronary artery bypass operations (13 women/87 men, aged 33-73 years, mean 58 years) without using homologous blood. A strict blood conservation programme was applied, with removal of autologous blood prebypass for retransfusion at the end of surgery, retransfusion of the heart-lung machine content to the patient, and autotransfusion of shed mediastinal blood in the postoperative period. All patients survived the operation and were extubated 1.6 hours (0-6) postoperatively. No patients needed resternotomy for bleeding, and no homologous blood was given. Five patients received 1-2 units of fresh frozen plasma because of coagulopathy. Mean hemoglobin was 12.0 g/100 ml and mean hematocrit was 36% at discharge from hospital. Elective coronary artery bypass surgery can be performed with little or no transfusions of homologous blood.

Restriction of donor blood transfusions in cardiac surgery should decrease the risk of infective contamination and antigenicity. Following a simple, systematic and inexpensive blood conservation program, we report on 250 consecutive patients undergoing elective coronary artery bypass surgery, 247 (98.6%) of whom did not need homologous blood transfusions. At least one internal mammary artery was grafted in all but one patient, in combination with saphenous vein grafts. Intraoperatively, autologous heparinized blood was removed before bypass and retransfused at the conclusion of extracorporeal circulation. The remaining volume of the oxygenator and tubing set was retransfused without any cell processing or hemofiltration. Using the hard-shell cardiotomy reservoir from the heart lung machine, autotransfusion of the shed mediastinal blood was continued hourly up to 18 h after surgery. The mean postoperative mediastinal bleeding was 622 +/- 287 ml, of which 589 +/- 296 ml was autotransfused. Five patients (2.0%) needed re-exploration for bleeding, and three of these received 1-4 units of homologous blood. No other patients needed red cell transfusions. Seven patients were given a mean of 2.6 units of fresh frozen plasma because of coagulopathy. Thus, altogether 240 patients (96%) were not exposed to any homologous blood products during their hospital stay. Morbidity was low. At discharge, the mean hemoglobin concentration was 12.0 +/- 1.4 g/dl and the mean hematocrit 36.0 +/- 4.2%. There were no deaths.

The effects of pulmonary flush with cold cardioplegic solution were investigated in 55 patients undergoing coronary artery bypass grafting. Extracorporeal circulation with bicaval cannulation was used in all cases, and single-dose cardioplegic solution was injected into the aortic root. In one of two randomly selected groups (n = 27) the cardioplegic solution was allowed to pass through the lungs and then evacuated via a left ventricular vent. In a second group (n = 28) the vent was first temporarily placed in the right atrium for evacuation of the cardioplegic solution, and the aortic root was vented later. Hemodynamic, metabolic, hematologic and radiographic changes were studied during the early postoperative period. No harmful effects of the pulmonary passage could be demonstrated. On the contrary, a protective effect was indicated, as the pulmonary vascular resistance index was reduced immediately and for 2 hours postoperatively. The ratio of left ventricular to right ventricular stroke work in the early postoperative period gave the same indication.