Bivalirudin anticoagulation during cardiac surgery: a single-center experience in 141 patients.

The feasibility of bivalirudin for anticoagulation during cardiac surgery has been confirmed in four multicenter clinical trials. Here, we report our single-center experience with bivalirudin anticoagulation in "on-pump" and "off-pump" cardiac surgery in a large number of patients with and without heparin antibodies. Data of patients who underwent cardiac surgery with bivalirudin anticoagulation between 06/2003 and 12/2007 at our institution were reviewed. Assessment included procedural success, blood loss, transfusion requirements, re-exploration rates and drug-related complications during the procedures. There were 141 patients treated with bivalirudin, of whom 40 had heparin antibodies. In 26 patients, "off-pump" coronary artery bypass grafting was performed and the remaining 115 patients had surgery with cardiopulmonary bypass (CPB). The procedural success rate after 7 days and after 30 days was 99.4%. The mean blood loss after "off-pump" surgery was 833 +/- 310 ml, with a transfusion rate of 30%. The mean blood loss after "on-pump" surgery was 750 +/- 494 ml, with a transfusion rate of 56%. Two patients needed re-exploration due to persistent hemorrhage. Overall transfusion rates were increased in patients with heparin antibodies. The current investigation demonstrates that, in experienced hands, bivalirudin anticoagulation can be performed with excellent procedural success and low complication rates during "on-pump" and "off-pump" cardiac surgery. Recent problems associated with the production of heparin have emphasized the urgent need for an alternative for use beyond the limited indication of heparin-induced thrombocytopenia.

Coronary surgery in patients requiring chronic hemodialysis.

BACKGROUND: In uremic patients coronary surgery and the entire perioperative management is demanding. METHODS: We analyzed retrospectively data from all patients requiring chronic hemodialysis who under went coronary artery bypass grafting (CABG) between January 1 2001 and December 31 2004 at the Deutsches Herzzentrum Berlin and compared them to those of a randomized nonuremic control group (n = 68), which consisted of patients who underwent CABG during the same period. RESULTS: During the study period 6315 patients underwent coronary artery bypass grafting at the Deutsches Herzzentrum Berlin. Among these patients, we identified 71 chronic dialysis patients (1.12%). Among dialysis patients, we recorded a perioperative mortality of 5.6%. One-year survival rate was 87.7% among uremic patients and 91.0% in the control group; the corresponding 4-year survival rates were 56.7 and 88.0%, respectively. The incidence of peripheral artery disease was significantly higher in the dialysis group. Uremic patients showed significantly lower hemoglobin serum levels at the time of admission compared to the control group (11.4 +/- 1.62 vs. 13.3 +/- 1.81 mg/dl). These patients received significantly higher numbers of blood transfusions (6.7 +/- 5.6 vs. 2.75 +/- 3.8), and platelet transfusions. CONCLUSION: Our preliminary study indicates that coronary surgery can be performed with acceptable mid-term results when the specific requirements of this patient group are taken into account.

Predictors of survival 1 hour after implantation of an intra-aortic balloon pump in cardiac surgery.

From July 1996 to March 2000, 391 patients with intraoperative cardiac low-output syndrome who underwent surgery with heart-lung bypass and had an intra-aortic balloon pump (IABP) implanted were analyzed in a prospective study. Of these 391 patients, 153 (39%) were operated on in an emergency situation, and 238 (61%) patients had elective surgeries. The perioperative mortality was 34% (133 patients). Clinical parameters were analyzed 1 hour after IABP support began. Statistical multivariate analysis showed that patients with an adrenaline requirement higher than 0.5 microg/kg/min, a left atrial pressure higher than 15 mmHg, output of less than 100 mL/hour, and mixed venous saturation (SvQ2) of less than 60% had poor outcomes. Using this data, we developed an IABP score to predict survival early after IABP implantation in cardiac surgery. We conclude that the success or failure of perioperative IABP support can be predicted early after implantation of the balloon pump. In patients with low-output syndrome despite IABP support, implantation of a ventricular assist system should be considered.