Preventing, minimizing, and managing postoperative bleeding.

BACKGROUND: Most bleeding in cardiovascular surgery is biological, not surgical, the result of disseminated intravascular coagulation in its latter phases. Disseminated intravascular coagulation bleeding affects all levels of the coagulation systems, requiring stabilization of the platelet system, balancing the procoagulant system and its regulation, and stopping the fibrinolytic system's activation. METHODS: The article discusses the multisystem protocol put into place at the Cardiovascular Surgery Department of La Pitié Hospital in Paris to diagnose and treat DIC bleeding so as to slow down causes of its occurrence and prevent further deterioration of the hemostatic systems. RESULTS: All biological bleeding was controlled, permitting detection of other causes of bleeding and allowing rational use of blood products. No thromboembolic accident occurred. There was an absence of iatrogenic bleeding. The protocol also detects disseminated intravascular coagulation in patients who did not bleed to take early and frequently lifesaving measures. CONCLUSIONS: This demonstrates the need to treat bleeding through a multisystem approach, monitoring its evolution by means of biological tests to be able to provide appropriate treatment.

Left centrifugal pump cardiac assist with transseptal percutaneous left atrial cannula.

Left cardiac support postcardiotomy requires a second operation for removal of the atrial cannula following weaning from assistance. To avoid the risk of this procedure, we used a transseptal cannula prototype. The cannula was introduced percutaneously through the femoral vein and advanced into the left atrium guided by the finger of the surgeon. Optimal positioning of the tip of the cannula was verified by perioperative transesophageal echocardiography. A long arterial cannula was positioned in the descending aorta via the femoral artery and a Carmeda circuit with a centrifugal pump was connected to both cannulas. This procedure was used in 3 patients with low cardiac output who underwent emergency surgery, a 63-year-old patient referred for aortic and mitral valve replacement, a 54-year-old man for aortic valve replacement, and a 64-year-old patient in the acute phase of myocardial infarction after myocardial revascularization. The assistance was used systematically at the end of the operation. The assist flow was 1.2-2.6 L/min. The patients were all weaned from support between 18 h and 8 days later. No complications related to the device occurred. Both cannulas were removed surgically from the femoral vessels without reopening the chest. This new procedure is of interest for 2 reasons: the systematic implantation allows for early assistance, and the use of a percutaneous approach avoids the risk of reopening the chest. More cases are needed to confirm this initial good impression.

Control and treatment of hemostasis in cardiovascular surgery. The experience of La Pitié Hospital with patients on total artificial heart.

The hemostasis protocol applied at the Cardiovascular Surgery Dept. of La Pitié Hospital has greatly reduced thromboembolic accidents and excessive bleeding, with consequent benefits for patients as well as cost reduction. Protocol also has been adopted for patients implanted with a circulatory assist device or a TAH. This paper presents our criteria on supervision and treatment of coagulation with such patients, who reflect all the acquired pathology in clinical hemostasis. From 04/86 to 07/94, 82 patients underwent TAH as a bridge to transplantation. Mean age: 38. Overall duration of mechanical support: 1930 days (mean: 23), of which 137 and 603 for 2 patients. Average duration of CPB: 150 min. Systematic approach to complex TAH-blood interaction and pre-operative multiple organ dysfunction used to control bleeding and/or thromboembolism after CPB. In addition to routine tests, specific regular testing was carried out at least once a day for platelet functions, for thrombin formation and its regulatory pathways, and for the fibrinolytic system. Patients were treated with small doses of Heparin, large doses of Dypyridamole, small doses of Aspirin, modulated doses of Aprotinin, Ticlopidine, Pentoxifylline, FFP, as well as Fibrinogen and AT III concentrates. Dosage was adapted to patient's clinical profile as well as to test interpretation criteria to provide personalized treatment. DIC, widely present in its different phases, was thus diagnosed and treated. All DIC bleeding was controlled, making it possible to detect other causes of post-operatory bleeding and use blood derivates rationally. There were no thromboembolic complications and no iatrogenic bleeding. TAH explanation shows no evidence of macroscopic clots in high risk sites, confirmed by microscopic analysis.

Reduction of haemorrhagic complications during mechanically assisted circulation with the use of a multi-system anticoagulation protocol.

Two different anticoagulation protocols were used in 49 consecutive patients mechanically supported either for bridge to transplantation (11) or for recovery of myocardial function after cardiac surgery (35). In 46 patients a Biomedicus centrifugal pump was used and in 3 patients a Pierce-Donachy ventricles. Mechanical support was provided to the left ventricle in 14 patients, to the right ventricle in 6 and to both ventricles in 12 patients; an extra-corporeal membrane oxygenator (ECMO) support was used in 17 patients. Thirty-seven males and 12 females, aged 0.2 to 58 years, were supported for an average time of 6.3 days (range 1-43). Anticoagulation was either based on a continuous infusion of heparin in the first 27 patients (group A) or on a multi-system therapy ("La Pitié" protocol) in the other 22 patients (group B). Overall survival rate was 47%. Patients in group A had a 30% (8/27) survival rate, whereas in group B a 68% (15/22) survival rate was observed (p = 0.006). Transplantation and ventricular assist device (VAD) removal was successfully obtained in 59% (16/27) and 91% (20/22) of patients in group A and group B respectively (p = 0.05). Significant bleeding occurred in 21 patients (81%) in group A and in 2 (9%) of group B (p = 0.001). In these patients bleeding averaged 230 +/- 231 ml/kg in group A versus 55 +/- 18 ml/kg in group B (p = 0.001). Surgical revision was necessary for cardiac tamponade or persistent bleeding in 12 patients of group A (25 procedures: mean 0.9/patient) and in 3 patients of group B (one each patient: mean 0.1/patient) (p = 0.01). Infection, thrombo-embolism and brain hemorrhage were also less frequent in group A than in group B. Our data suggest that the "La Pitié" protocol provides a better control of bleeding than the conventional heparin infusion in patients receiving assist device. this reduction in thrombo-hemorrhagic complications might improve the results of mechanical circulatory support.

Clinical experience with a total artificial heart as a bridge for transplantation: the pitie experience.

Since April 1986, 82 patients have received a pneumatic total artificial heart, 62 a JARVIK-7, and 20 a Cardiowest. The duration of support ranged from less than 1 day to 603 days (mean duration: 27 +/- 82). The indications were for acute shock (38 cases) or for chronic deterioration on the transplant waiting list (44 cases). The etiology was mainly due to idiopathic and ischemic cardiomyopathy. With the help of our scoring system, we divided our patients in three groups: Chronic Implantation, represented by two females staying on device for 6 and 19 months, respectively; a High-Risk group of 29 patients characterized by high-risk indications; graft failure, rejection, postcardiotomy patient, postpartum cardiomyopathy, and valvular and congenital reoperation. In addition, the dilated and ischemic cardiomyopathy patients with a score over 6 were included in this group; and an Elective Indication group (51 patients) represented all of the dilated and ischemic cardiomyopathy patients with a score under 6. Due to the shortage of donors, our criteria for transplantation are very strict. Transplants should be made only in cases of hemodynamic stability, on an extubated patient with normal renal and liver functions, without coagulation problems or infection. With such criteria, in the high-risk group, only four patients could be transplanted and of these two are still alive. In contrast, in the elective group, 31 were transplanted (61%), and 71% of these patients were discharged. The rate is improved in the most recent cases, with 90% of the Cardiowest patients being survivors.

Heart and heart-lung transplantation in the 1990s.

After 22 years of clinical application in our unit, heart transplantation is now an accepted therapeutic method. Its indications are well established, its surgical technique and post-operative control and treatment well defined, mostly due to better diagnosis of the rejection episodes with the aid of echocardiography and endomyocardial biopsy and the use of cyclosporin. The results are remarkable with a survival rate of 70% at 5 years, and a full rehabilitation into family, social and often professional life for almost all the survivors. Its use has dramatically changed the prognosis of patients with irreversible cardiac failure but underlines the lack of a sufficient number of donors' hearts. The heart-lung transplantation, making use of the progress of heart transplantation, has been used successfully since 1982 and for the first time in Europe by our group. Improvement in the selection of recipients, lung preservation, surgical technique and post-operative management have brought a new and real hope to patients not only irreversible cardiopulmonary lesions but also terminal pulmonary disease.

Mechanical circulatory support as a bridge to transplantation: current status of total artificial heart in 1989 and determinants of survival.

Since April 1986, 40 total artificial hearts (TAH) were implanted as a bridge to transplantation in our institution. In an attempt to identify factors affecting survival of TAH recipients we reviewed our experience over 1000 days of mechanical support. There was no postoperative bleeding requiring surgery nor were there any clinical episodes of thromboembolic complications. Over a total functioning period greater than 3 years there were no mechanical failures in the driving system but one artificial ventricle had to be replaced because of mechanical dysfunction. Infections and multiple organ failure were the primary causes of morbidity and mortality during mechanical support. When the patients who underwent staged transplantation (no. 17) were compared with those who died during mechanical support (no. 23) there were no differences in TAH driving mode or hemodynamic variables between the groups. Although preoperative pulmonary, hepatic and renal functions were found to be similar between the groups, there were significant differences in the early evolution (3 days) of hepatic and renal functions following TAH implant (p less than 0.01). Urinary output was found to be the earliest variable discriminating recovery and survival (p less than 0.01). Finally, univariate analysis indicated age (less than 40 vs greater than 40 years) and modality of cardiac decompensation (acute vs chronic) as the most important factors affecting survival after TAH implantation. Since young patients (less than 40 years of age) with acute decompensation were successfully transplanted in 82% of cases while 100% of older patients with chronic decompensation died before or after transplantation, TAH should be advised in young patients with acute or chronic heart failure and in selected older candidates with recent, acute cardiac failure.

Orthotopic transplantation after implantation of a Jarvik 7 total artificial heart.

A total artificial heart was used to support the circulation in 33 heart transplantation candidates who were expected to die before procurement of a donor heart. Twelve of these patients (mean age 35 +/- 10 years) underwent cardiac transplantation. Another patient is still being supported with the total artificial heart 90 days after implantation. The other 20 patients died during mechanical support because their condition could not be stabilized for transplantation, despite blood flow restoration. Fifty-six percent of the patients younger than 40 years underwent successful transplantation and six of nine patients are long-term survivors. By comparison, in the older group, 17.6% of patients underwent transplantation and one of three survived long term. Forty-four percent of patients in the acute decompensation group had successful transplantation and four of seven patients are long-term survivors. In the chronic decompensation group these figures were 29.4% and three of five patients. All patients who were heavily immunosuppressed (n = 4) died of sepsis. Transplantation was considered and performed only when the patient's condition was correct and stable. In six patients an infection developed in the immediate posttransplant period. Three of the infections were resolved with antibiotic therapy. One originated in the mediastinum and is still unresolved, although the patient's condition is improving. Another patient died of an anoxic coma caused by ventilatory problems. There were two late deaths at 14 and 19 months, one resulting from a combination of toxoplasmosis and rejection and the other from a Kaposi sarcoma caused by azathioprine treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Total artificial heart: survival and complications.

A total artificial heart was implanted in 28 patients as a bridge to transplantation. Mean time of mechanical support was 14.8 +/- 10 days. The 70-mL Jarvik-7 was used in 12 patients and the 100-mL Jarvik-7 in the remaining 16. No clinical thromboembolic complications occurred during implantation. There was no postoperative bleeding requiring operation. Both survival and the rate of complications were similar in the two Jarvik-7 groups. Eleven patients underwent successful transplantation, and 1 patient is still on mechanical support. Sepsis and multiple-organ failure were the most important causes of death. All patients receiving the total artificial heart for severe acute rejection after transplantation died of infection. Early implantation of the total artificial heart is advised in younger patients and in older patients with acute cardiac failure. The use of this device should be contraindicated in immunosuppressed patients because of the high risk of infection.

Clinical application and patient selection in the use of a total artificial heart as a bridge for transplantation.

Between April 1986 and July 1987, 21 patients underwent orthotopic implantation of a total artificial heart (Jarvik 7) at La Pitié Hospital. There were 18 men and 3 women with a mean age of 37.3 +/- 11.4 years. The device implanted was the 70 ml version in 10 patients and the 100 ml version in 11 patients. In the results, three variables were analysed: age, acute myocardial decompensation or chronic myocardial failure, and aetiology of the 21 patients treated. 10 (47.6%) had adequate support and were successfully transplanted. Eleven patients (52.4%) died during circulatory support. The main causes of death were sepsis and multiple organ failure. In only one patient was a mismatch between the heart and chest cavity present. There was no clinical evidence of thromboembolic complications. Patients of 40 years of age and less have an 80% chance of being successfully transplanted in comparison with a 25% success rate in older patients. Patients that developed sudden cardiac decompensation have a 75% success rate for transplantation in comparison with 44.4% success rate in patients with a chronic illness. Early implantation of the device, before the development of irreversible damage in other organs, is recommended in younger patients with acute or chronic disease and in older patients with acute myocardial failure. The use of this device is contraindicated in immunosuppressed patients due to the high risk of infection.