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Ann Thorac Surg 2002;73:743-744
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Section of Cardiothoracic Surgery, Yale University School of Medicine, 333 Cedar St, 121 FMB, New Haven, CT 06510, USA

e-mail: john.elefteriades{at}yale.edu

Elective surgery for the thoracic aorta has become safer than ever before [1, 2]. Much of this improved safety is due directly to improvements in hemostasis. Routine use of activated clotting time (ACT) to guide heparin reversal use of antifibrinolytic agents, advent of water-tight collagen-impregnated grafts, and availability of biological glues have all contributed to hemostatic enhancement. As aortic surgery has become safer and more routine, attention has become focused on blood conservation in aortic surgery, which previously took a back seat to issues of achieving survival, avoiding stroke, and preventing paraplega.

Shibata and colleagues provide an important contribution by demonstrating that many patients can avoid blood transfusions in aortic surgery through a concerted blood conservation program. Intraoperative blood salvage is commonly practiced in all types of cardiac surgery. The cornerstone of the approach taken by Shibata’s group is large volume preoperative auto-donation of blood (1600 mL or greater).

Two main issues arise with this approach. First, there is some finite danger inherent in delaying surgery for weeks or months to permit multiple auto-donations and blood regeneration. Although the rupture risk for most aneurysms is expressed over months to years, every busy aortic program encounters rupture deaths during the work-up phase. Recent reports suggest that for aneurysm size greater than 6 cm, the monthly rate of rupture, dissection, or death would be greater than 1% per month [3]. Such a rupture rate would dwarf the rate of potential transmission of HIV from blood transfusion. There exists also a theoretical concern that hemodilution from phlebotomy may engender a hyperdynamic response (increased dp/dt) that may increase the susceptibility to rupture. Patients with symptomatic or extremely large or rapidly growing aneurysms should probably undergo traditional prompt operative scheduling, without prolonged delay for blood harvesting.

The second issue is a "horse and cart" or "chicken and egg" paradox. Do the authors believe that blood transfusion caused the complications observed in the transfusion group (prolonged ventilation, infection, renal failure, death)? Is it not likely that these transfused patients had a more complicated course (intraoperatively or postoperatively, especially in terms of bleeding) and thus required blood transfusion? The complications cited may be the result of the more complicated course rather than the blood transfusions per se.

Doctor Shibata and his group have made a significant contribution by demonstrating that major aortic thoracic surgery can be done without blood transfusion by supplementing routine conservation methods with large-volume, preoperative auto-donations of the patient’s own blood.

References

1. Svensson L.G., Sun J., Nadolny E., Kimmel W.A. Prospective evaluation of minimal blood use for ascending aorta and aortic arch operations. Ann Thorac Surg 1995;59:1501-1508.[Abstract/Free Full Text]
2. Davies R., Rizzo J., Kopf G., Elefteriades J. Safety of thoracic aortic surgery in the present era. Circulation 2001(Suppl II):11643.
3. Davies R., Goldstein L., Coady M., et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg 2002;73:17-28.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John A. Elefteriades Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Elefteriades, J. A. Search for Related Content PubMed Articles by Elefteriades, J. A. Related Collections Related Article