Ann Thorac Surg 1999;67:1273
© 1999 The Society of Thoracic Surgeons
Invited Commentary
Richard J. Shemin, MDa
a Department of Cardiothoracic Surgery, Boston University and, Boston Medical Center, 88 East Newton St, Boston, MA 02118-2393 USA
Invited commentary
This study of high-risk reoperative cardiac surgical patients adds to the growing literature that heparin-coated circuits are safe and adds significant benefit to patients requiring cardiopulmonary bypass for operations. Laboratory and clinical studies have consistently demonstrated a reduction in the measurable variables induced by the inflammatory response to cardiopulmonary bypass (ie, complement, leukocyte, cytokine, and platelet activation). Even though the biochemical data is compelling, reported clinical data have been variable, resulting in a lag in the total acceptance of the heparin-coated technology as the new standard. This situation is similar to a previous advance in perfusion technology, the membrane oxygenator. It took years until the profession accepted the strong biochemical data favoring the superiority of the membrane oxygenator because of inconsistent studies demonstrating clinical outcome improvement and higer cost. Heparin-coated circuits are at the same stage. The current cost differential for heparin-coated circuits, a previous negative factor, is becoming negligible, approximately $50 to $100/case. This cost is more than accounted for when reduced blood products and reduced procedural morbidity is considered.
Our group at Boston Medical Center has used heparin-coated circuits as the standard for 5 years since conducting our prospective randomized studies, which were published in this journal in 1996. We believe the variable clinical results reported by other investigators are related to a failure to incorporate several other very important blood conservation strategies to their perfusion protocols. We and others have shown the powerful, but safe, impact of a reduced anticoagulation protocol in blood utilization and clinical outcomes. We avoid using pericardiotomy suction if at all possible and have abandoned the retransfusion of shed mediastinal blood, both of which contain highly activated tissue factors and tissue-type plasminogen activator. The use of a closed system minimizes the gas to blood interface, which plays a significant role in activation. We predict that heparin-bonded circuits will prove to be one of the more significant advances in the quest for biocompatibility in perfusion. However, the circuits alone will not be sufficient. Protocols incorporating the principles outlined will help achieve the maximal patient benefit, which would be immediately apparent to the surgeon.
Related Article
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A prospective randomized trial of Duraflo II heparin-coated circuits in cardiac reoperations
- Patrick M. McCarthy, Jean-Pierre P. Yared, Robert C. Foster, David A. Ogella, Judith A. Borsh, and Delos M. Cosgrove, III
Ann. Thorac. Surg. 1999 67: 1268-1273.
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