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Ann Thorac Surg 1999;68:1656
© 1999 The Society of Thoracic Surgeons

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Invited Commentaries

^a Department of Anesthesia, Massachusetts General Hospital, Boston, MA 02114, USA

Invited commentary

Doctor Kiyama and colleagues add to the evidence that preoperative recombinant erythropoietin (RHuEPO) and oral iron therapy effectively reduces the need for red blood cell transfusion during cardiac operations. Their patient population with anemia and small stature (body surface area, 1.5 m²) selects for the ideal candidates for RHuEPO therapy, that is, those coming to operation with reduced red cell mass. They demonstrate that red cell enhancement has a separate effectiveness profile from blood loss reduction (aprotinin). Furthermore, their work suggests that aprotinin may not be important in patients with red cell mass deficiency and no risk factors for bleeding.

They do not answer several important questions. Is the addition of preoperative autologous blood harvest to RHuEPO/iron necessary? There is evidence that allowing patients to bank their own blood intravascularly works just as well, with less invasiveness and cost. Each autologous cell harvest in Dr Kiyama’s study involved significant costs: harvest and handling, a laboratory test, and a nonstandard harvest goal that had to be adjusted based on the results of the laboratory test. Allowing the red cell mass to increase without harvesting eliminates these costs. Of course the safety of forcing a rapid preoperative red cell mass increase in cardiac surgical patients remains to be compared with the safety of multiple preoperative blood donations.

The primary safety outcome, perioperative death, remains inadequately addressed in this study. Our multicenter experience with RHuEPO in cardiac surgical patients demonstrated a nonsignificant increase in death during a 6-month perioperative period in the erythropoietin-treated group versus placebo. Statistical nonsignificance notwithstanding, the Food and Drug Administration has consequently required the drug to be labeled as "not indicated in cardiac and vascular surgery." It would be useful if future studies of RHuEPO report not only operative, but also perioperative death. Perhaps outcome databases such as The Society of Thoracic Surgeons database could include a field for preoperative RHuEPO use to further address this most important safety question.

Related Article

Autologous blood donation with recombinant human erythropoietin in anemic patients

Hiroshi Kiyama, Nagahisa Ohshima, Takao Imazeki, and Takashi Yamada
Ann. Thorac. Surg. 1999 68: 1652-1656. [Abstract] [Full Text] [PDF]

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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by D’Ambra, M. N. Search for Related Content PubMed Articles by D’Ambra, M. N. Related Collections Related Article