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Ann Thorac Surg 1999;68:1640-1643
© 1999 The Society of Thoracic Surgeons

Original Articles

Blood product use in cardiac revascularization: comparison of on- and off-pump techniques

Nader D. Nader, MDa, Wiam Z. Khadra, PhDa, Neal T. Reich, MDb, Douglas R. Bacon, MDb, Tomas A. Salerno, MDa, Anthony L. Panos, MDa

a Division of Cardiothoracic Surgery, State University of New York at Buffalo, and the Veterans’ Administration Western New York Healthcare System, Buffalo, New York, USA
b Department of Anesthesia, State University of New York at Buffalo, and the Veterans’ Administration Western New York Healthcare System, Buffalo, New York, USA

Address reprint requests to Dr Nader, Anesthesiology Service, VA Medical Center, 4300 W 7th St, Little Rock, AR 72205
e-mail: nnader{at}med.va.gov


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Cardiac revascularization on a beating heart avoids the side effects of cardiopulmonary bypass (eg, neurologic injury, hemodilution, and coagulopathy). We examined perioperative bleeding and use of blood products during coronary artery bypass grafting using either on-pump or off-pump techniques.

Method. The charts of 126 patients who had coronary artery bypass grafting were reviewed. Data from 66 patients revascularized off pump and 60 patients with cardiopulmonary bypass (on pump) were analyzed using unpaired Student’s t test.

Results. Average age was 62.5 years in either group. More patients received heparin preoperatively in the off-pump group that resulted in mild elevation of preoperative partial thromboplastin time and activated clotting time (40.4 ± 2.9 seconds and 150.1 ± 5.3 seconds, respectively). However, the off-pump group had less perioperative (intraoperative or postoperative) bleeding (2312 ± 212 mL versus 3251 ± 155 mL, p < 0.05) and required fewer blood products compared with the on-pump group. Hemoglobin and platelets decreased more in the conventional on-pump group.

Conclusions. Avoiding cardiopulmonary bypass decreases perioperative bleeding and, consequently, reduces the use of blood products after coronary artery bypass grafting, which might result in fewer transfusion-related complications.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Perioperative bleeding and transfusion-related complications are among the major risks associated with open heart procedures. Most patients who have cardiac operations receive transfusion at some time during their hospital course. In more than 27% of these circumstances transfusion could have been avoided [1]. Hemostasis during cardiac operations is challenging and sometimes expensive. Several comprehensive multimodal blood conservation protocols have been adopted to decrease blood loss and the need for transfusion after cardiac surgical procedures [2]. However, most of these protocols advocate increasing the threshold for transfusion in these patients, which may not be feasible in an elderly population.

The refinement of extracorporeal circulation during the past 30 years has allowed surgeons to treat many cardiac pathologies. The quiet, motionless, and essentially bloodless field that is provided with the diversion of circulation has allowed surgeons to have unparalleled access to intracardiac and extracardiac structures. Limitations once thought insurmountable no longer exist with the evolution of myocardial protective measures and cardioplegia. However, the search for alternative methods to cardiac operations without extracorporeal bypass continued because of the hematologic, neurologic, and cognitive dysfunction noted to follow cardiopulmonary bypass (CPB) [1–7].

Because CPB affects the coagulation cascade in several ways, we examined the difference in the requirement of blood products in patients who had coronary artery bypass grafting (CABG) using conventional CPB (ie, on pump) and patients who had CABG with the heart beating (ie, off pump). The study examined the use of packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate. Perioperative bleeding during the CABG procedure with and without CPB was also examined.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
This study was performed at the Buffalo Veterans Administration Medical Center from September 1997 to August 1998. The retrospective nature of this study led institutional review board exemption from obtaining informed consent and assured no selection bias. The charts of 133 patients who had CABG by the same surgeon were reviewed. Seven patients (4 from the off-pump group and 3 from the on-pump group) who returned to the operating room with documented surgical bleeding were excluded from the review irrespective of study arm.

A total of 66 of the remaining 126 patients were revascularized without CPB (off pump), and 60 patients had CABG with CPB (on pump). Physical status was evaluated preoperatively by using the American Society of Anesthesiology classification system. Angina was classified using the Canadian Cardiovascular Society classification, and cardiac function was assessed using the New York Heart Association classification. Demographic data were reviewed and analyzed for differences in age, physical status, angina class, and cardiac function. Left ventricular ejection fraction was quantified by preoperative angiogram.

The presence of recent myocardial infarct was documented if it occurred within 6 months of the operation. Total number of packed red blood cells, fresh frozen plasma, platelet-rich plasma, and cryoprecipitate units were recorded. The prothrombin time, partial thromboplastin time, activated clotting time, and total platelet count were examined preoperatively and postoperatively. Preoperative use of heparin or aspirin was also recorded. Hemoglobin concentrations were recorded preoperatively and postoperatively. Once all of the data were acquired and recorded, they was analyzed using unpaired Student’s t test, {chi}2, and Fisher’s exact test where appropriate.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Analysis of demographic data revealed no differences between the off-pump and on-pump groups. Average age was similar in both study groups (62.3 ± 9.5 versus 62.5 ± 10.5 years). Approximately 90% of the patients in both groups were in American Society of Anesthesiology class 3 or 4. The remaining 10% were classified as emergent cases (American Society of Anesthesiology class 3E or 4E). Emergency classification was based on the urgency of the operation; however, only 1 patient was a catheterization laboratory rush case who had received only heparin infusion without addition of new generation antiplatelet drugs. This patient was revascularized using CPB. Mean left ventricular ejection fraction was 49% ± 6% in the off-pump group that was not different from left ventricular ejection fraction of the on-pump group of patients (51% ± 7.2%). Previous history of recent myocardial infarction was similar between groups. Overall, the stratification of American Society of Anesthesiology classes, the presence of previous infarct and left ventricular ejection fraction were all statistically similar (Table 1).


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  		Table 1. Demographic Data From 126 Patients Who Had Coronary Artery Bypass Graftinga

 
There were no differences in preoperative platelet count (205.0 ± 51.3 versus 189.7 ± 54.4) and hemoglobin concentrations (13.8 ± 1.2 versus 14.9 ± 0.9 mg/dL) between groups. More patients received preoperative heparin in the off-pump group. This resulted in a mild increase in partial thromboplastin time (40.4 ± 2.9 versus 34.7 ± 3.6 seconds) and activated clotting time (150.1 ± 13.3 versus 130.5 ± 10.5 seconds) in this group compared with the on-pump group (p < 0.05). Preoperative use of aspirin, however, was similar between groups (Table 2). Despite the aforementioned relative prolongation of partial thromboplastin time and activated clotting time and a lower (but not statistically significant) starting preoperative hemoglobin, the off-pump group had less perioperative (intraoperative plus postoperative) bleeding. Intraoperative blood loss as assessed by calculating the amount of cell-saver transfusion and was lower in off-pump group compared with on-pump group (508 ± 64 versus 715 ± 50 mL). These patients also had lower postoperative drainage from chest tubes in first 24-hour period compared with on-pump patients (771 ± 66 versus 1084 ± 82 mL, p < 0.05) (Fig 1). Additionally, the off-pump patients required significantly fewer blood products than the on-pump group. The off-pump patients needed, on average, 2.25 units less of packed red blood cells, 1.75 units less of fresh frozen plasma and 3.75 units less of platelet-rich plasma (p < 0.05, Fig 2). Cryoprecipitate was used for only 1 patient in on-pump group for the amount of 20 units.


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  		Table 2. Coagulation Profile Obtained Preoperatively

 


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  		Fig 1. Perioperative bleeding with intraoperative use of cell-saver blood transfusion and 24-hour postoperative drainage from the chest tubes (CT) were significantly less in the off-pump group compared with the on-pump group (p < 0.05).

 


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  		Fig 2. The use of blood products is shown as the number of the units that were used during hospitalization for the CABG. The difference is statistically significant for all three types of products. (PRBC = packed red blood cells; FFP = fresh frozen plasma; PRP = platelet rich plasma.)

 
When we examined the percentage changes in hemoglobin and platelets we found a difference between on-pump and off-pump groups. Although 25% and 23% decreases were noted in hemoglobin concentrations and platelet counts, respectively, from preoperative values in off-pump patients, there was a 36% decrease in hemoglobin and a 38% decrease in platelet counts in patients who had revascularization by the conventional on-pump method (Fig 3). Preoperative difference in partial thromboplastin time was lost postoperatively because of heparin reversal. Prothrombin time did not differ significantly from preoperative values in either group.



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  		Fig 3. Percentage change in hemoglobin concentration (A) and platelet counts (B) associated with the surgical procedure. Asterisks indicate significant (p < 0.01) differences.

 
Additional data analysis revealed that the number of the grafts was similar between groups (2.4 ± 0.3 versus 2.5 ± 0.4 grafts). On an average, the off-pump patients stayed 2.1 days in the intensive care setting and had an average operating room time of 5.5 hours, which were comparable to those of the patients in the on-pump group.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
The goal of this study was to evaluate blood use in patients who had CABG. The resurgence of off-pump cardiac procedures led to the hypothesis that avoidance of CPB may lead to a change in blood product use. Although the retrospective nature of this study did not allow us to randomly assign patients to groups, data analysis showed that the two populations were similar. Although we cannot account for patient selection bias that might have occurred because of additional patient risk factors such as unstable angina or other comorbidity, data analysis confirmed that the groups were similar with regard to American Society of Anesthesiology, Canadian Cardiovascular Society, New York Heart Association class and left ventricular function. The off-pump group even started with high partial thromboplastin time and activated clotting time and yet had less perioperative bleeding and used fewer blood products. These findings are similar for each type of blood product.

The initial work in CABG was done in the era before CPB was refined. Vineberg [8] implanted an internal mammary artery into cardiac muscle in 1946, and Murray and associates [9] and Sabiston [10] modified the technique. Kolessov [11] revascularized the left anterior descending artery and marginal branch of the circumflex artery by the left internal mammary artery through a left thoracotomy without CPB. These initial reports were followed by the off-pump bypass experiences of Favaloro [12], Garrett and colleagues [4], Trapp and Bisarya [13], and Ankeney [3]. Those experiences occurred concurrently with the development of cardioplegia and CPB. The precision and control, with a motionless and bloodless field, led to the abandonment of off-pump CABG techniques.

Despite the encouraging results of the aforementioned off-pump procedures, the technical difficulty inherent in operating on a beating heart and having to bypass posteriorly positioned coronary vessels required patience and proper patient selection. However, despite the relatively few operations done and the few surgeons working off pump, there still was a benefit in patient recovery time. This procedure has recently become more standardized, simplified, and refined. Although CPB remains the gold standard for safety and efficacy in revascularization, off-pump bypass is now becoming a more acceptable and common procedure. Although many physicians remain skeptical, this technique has begun to show reductions in complications, recovery time, and cost [14, 15].

With the decrease in blood product use with off-pump bypass techniques, there may be a concurrent decrease in the risk of transmitting blood-borne pathogens, blood transfusion reactions, and the associated risk of nonautologous transfusion. In addition, off-pump bypass may be as safe or safer than conventional CPB. It is easier for a surgeon to do coronary revascularization with the still, bloodless field offered by CPB, but it might be less traumatic and hazardous for the patient to have an off-pump procedure. The data suggest that there is less bleeding with off-pump procedures compared with CPB, which might be a result of the partial heparinization technique used in off-pump revascularization compared with the full heparinization used in conventional CPB.

The advent of these new techniques has made myocardial revascularization possible without the need to use CPB exclusively. This study clearly showed that there is less need for blood products and no additional operating room time or intensive care unit stay. Therefore, hemodynamic dysfunction and coagulopathy are not the only potential benefits of the off-pump technique. If studies show that there are also fewer neurologic sequelae, less intraoperative myocardial damage, and less renal damage, the number of off-pump cases might continue to increase. Decreasing postoperative complications is the next logical step to improving outcomes of cardiac operations.

These data were collected during our initial experience with off-pump CABG. Even in these initial phases we noticed savings in blood usage. We believe that with increasing experience further improvements are possible.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Harmon D.E. Cost/benefit analysis of pharmacologic hemostasis. Ann Thorac Surg 1996;61(Suppl):S33-S34.
  2. Helm R.E., Rosengart T.K., Gomez M., et al. Comprehensive multimodality blood conservation. Ann Thorac Surg 1998;65:125-136.[Abstract/Free Full Text]
  3. Ankeny J.L. To use or not use the pump oxygenator in coronary bypass operations. Ann Thorac Surg 1975;19:108-109.[Medline]
  4. Garrett H.E., Dennid E.W., DeBakey M.E. Aorto-coronary bypass with saphenous vein graft. JAMA 1973;223:792-794.[Abstract/Free Full Text]
  5. Edmunds L.H., Woodward B. Effects of tumour necrosis factor-alpha on the coronary circulation of the rat isolated perfused heart. Br J Pharmacol 1998;124:493-498.[Medline]
  6. Bruggemans E.F., Van Dijk J.G., Huysmans H.A. Residual cognitive dysfunctioning at 6 months following coronary artery bypass graft surgery. Cardiothorac Surg 1995;9:636-643.
  7. Robin E.D., McCauley R.F., Notkin H.G. Long-term cognitive abnormalities associated with cardiopulmonary bypass (CPB) and the Babel effect. Chest 1994;106:278-281.[Abstract/Free Full Text]
  8. Vineberg A.M. Development of anastomosis between coronary vessels and transplanted mammary artery. Can Med Assoc J 1946;55:117-121.
  9. Murray G., Porcheron R., Hilario J., Rosenblau W. Anastamosis of a systemic artery to the coronary. Can Med Assoc J 1954;71:594-597.
  10. Sabiston D.C., Jr The coronary circulation. Johns Hopkins Med J 1974;134:314-329.
  11. Kolessov V.L. Mammary artery-coronary artery anastomosis as a method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967;54:535-544.[Medline]
  12. Favaloro R.G. Saphenous vein autograft replacement of severe segmental coronary artery occlusion. Ann Thorac Surg 1968;5:334-339.[Medline]
  13. Trapp W.S., Bisarya R. Placement of coronary artery bypass graft without pump oxygenator. Ann Thorac Surg 1975;19:1-9.[Medline]
  14. Buffolo E., Succi A.J., Leao L.E.V., Galluci C. Direct myocardial revascularization without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1985;33:26-29.
  15. Buffolo E., de Andrade C.S., Branco J.N., Teles C.A., Aguiar L.F., Gomes W.J. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
Accepted for publication May 7, 1999.




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