ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Raimondo Ascione
Gianni D. Angelini
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Ascione, R.
Right arrow Articles by Angelini, G. D.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Ascione, R.
Right arrow Articles by Angelini, G. D.
Related Collections
Right arrow Minimally invasive surgery

Ann Thorac Surg 2003;75:1362-1363
© 2003 The Society of Thoracic Surgeons

Correspondence

A request for clarification: Reply

Raimondo Ascione, MD, Barnaby C. Reeves, PhD, Gianni D. Angelini, FRCS

Department of Cardiac Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom

To the Editor:

We thank Dr Millner for his comments. The main aim of our observational study [1] was to assess the overall effectiveness of off- and on-pump coronary surgery in high-risk patients. We did not focus on blood-saving techniques because in this group of patients many confounding variables may affect blood loss and transfusion requirement. Such end points are best investigated with controlled trials like the BHACAS 1 and 2 [2], recently conducted at our institute, which showed that blood loss and transfusion requirement were significantly higher in the on-pump compared with the off-pump group. In the off-pump group, less than 5% of patients required fresh-frozen plasma (FFP) and platelet (PLT) units, while in the on-pump group, it was 30% and 25%, respectively. These findings were supported by the significantly higher derangement of hematological and coagulation indices observed in the on-pump group [3].

After these results, since the beginning of 1999, we have used tranexamic acid (TA) in patients undergoing on-pump coronary surgery. Simultaneously, we started to use, selectively, the cell saver (CS) during off-pump coronary surgery, when the procedure is performed by a supervised trainee, and when temporary proximal coronary snaring is not used before the insertion of the intracoronary shunt either because of contraindication or surgeon preference. Due to this selective practice, the use of CS in the off-pump group of our high-risk series [1] was 39% (19% over the same period in the whole off-pump population).

Following Dr Millner’s comments, we have performed a new adjusted logistic regression analysis for blood loss and transfusion requirement, including in the statistical model the use of TA and CS as well as all other previous variables (Table 1). This analysis confirmed that the effect of off-pump surgery on blood loss >1,000 mL was not significant. However, the use of off-pump surgery still had a significant effect on any red blood cell (RBC) and PLT transfusions. Interestingly, despite the higher requirement of RBC transfusion in the on-pump group, on discharge, a hemoglobin level < 10 g/dL was recorded in 47% of patients in this group as compared with 29% in the off-pump group. The effect of off-pump surgery on the use of any FFP transfusion was moderately significant in the original adjusted analysis, but only reached a borderline significance in the new model.


View this table:
[in this window]
[in a new window]
  		Table 1. Effect of Off-Pump Versus On-Pump Surgery: Original and New (Inclusive of Use of Cell Saver or Tranexamic Acid) Adjusted Effect Sizes

 
The new adjusted analysis, therefore, confirms our original findings. These seems to be supported by most of the reports in the literature, which show either similar or lower blood loss with off-pump coronary surgery, and a unanimous reduction in transfusion requirement when compared with conventional technique [4].

References

  1. Chamberlain M.H., Ascione R., Reeves B.C., Angelini G.D. Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study. Ann Thorac Surg 2002;73:1866-1873.[Abstract/Free Full Text]
  2. Angelini G.D., Taylor F.C., Reeves B.C., Ascione R. Early and mid-term outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002;359:1194-1199.[Medline]
  3. Ascione R., Williams S., Lloyd C.T., et al. Reduced post-operative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomised study. J Thorac Cardiovasc Surg 2001;121:689-696.[Abstract/Free Full Text]
  4. Ascione R, Caputo M, Angelini GD. Off-pump coronary artery bypass grafting: not a flash in the pan. Ann Thorac Surg 2003;75:306–13




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Raimondo Ascione
Gianni D. Angelini
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Ascione, R.
Right arrow Articles by Angelini, G. D.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Ascione, R.
Right arrow Articles by Angelini, G. D.
Related Collections
Right arrow Minimally invasive surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS