Blood Saving Strategies and Results of Fibrin Sealing in Cardiovascular Surgery

Abstract

Surgical operations under systemic anticoagulation with heparin can cause severe bleeding problems. Of our cardiovascular operations 80% are performed with cardiopulmonary bypass (CPB) and therefore need intraoperative systemic anticoagulation with heparin (400 U/kg BW corresponding to an ACT > 400 s). In our clinic we have developed an intraoperative strategy to minimize postoperative bleeding to avoid the transfusion of blood samples as often as possible. Our efforts to minimize postoperative bleeding after CPB include three major steps: (a) fibrin sealing in combination with the application of collagen sheets in critical areas to prevent nonsurgical bleeding; (b) application of aprotinin (Trasylol) up to a plasma concentration of 200 KIU/ml during CPB; and (c) in elective cardiac surgery whenever possible; preparation of two erythrocyte samples and two fresh-frozen plasmas of the patient’s own blood donated 2–4 weeks before the planned operation. Our indications for the use of fibrin sealing and the application of a collagen sheet include: (a) coronary anastomoses after thrombectomy, in calcified coronaries and in cases of excessive epicardial lipomatosis; (b) coronary anastomoses performed with local arteries (a. thoracica interna, a. gastroepiploica, a. gastrica); (c) stabilizing the local course of vein bypass grafts; (d) coronary anastomoses in coronary bypass reoperations; (e) sealing the stitch holes of sewed-in patches (pericardium, polytetrafluoroethylene, polyethylene therephthalate) in congenital heart diseases; (f) sealing the sutures after atriotomy, ventriculotomy and aneurysmectomy; and (g) sealing the dead space between the two aortic walls after implantation of homo- or allograft in the mini-root technique in aortic position. In 1990 and 1991 a total of 2412 operations with CPB were performed in our clinic. Of these, 364 patients underwent emergency cardiovascular surgery (15.1%). The overall (30-day) mortality was 3.2%. In 231 cases (9.5%) congenital heart diseases and in 409 cases (16.95) acquired heart defects were corrected. In 75 cases (3.1%) antiarrhythmic operations were performed. There were also 1619 (67,1%) coronary bypass operations and 32 (1.3%) heart transplantations. The remaining operations were replacements of the thoracic aorta (2.1%). Transfusion of blood was not required in 63% of all operations. The 15.1% emergency operations were performed without blood transfusions in 57% of cases. Urgent cardiovascular surgery was performed in 17% (410 cases) and could be finished in 60% without any blood transfusions. Fibrin sealing plays an important role in preventing nonsurgical bleeding after CPB surgery. However, the beneficial use of fibrin sealing is guaranteed only if the application is limited to prevent nonsurgical bleeding. Pulsatile surgical bleeding never can be stopped by the application of fibrin glue. In our opinion, the combination of these methods is of enormous benefit to minimize blood transfusions and thus the infectious risk for patients undergoing cardiovascular surgery.