Extra-corporeal membrane oxygenation for the post-cardiotomy patient.

Extra-corporeal membrane oxygenation remains the last resort in keeping patients alive in those with profound cardiogenic shock following percutaneous interventions or open surgery on the heart. No guidelines exist on the management of patients on such a device despite a high mortality. We attempt to highlight some universal principles that would be relevant to the current practice of those exposed to this challenging field.

Mini-extracorporeal circulation technology, conventional bypass and prime displacement in isolated coronary and aortic valve surgery: a propensity-matched in-hospital and survival analysis.

OBJECTIVES: Conventional cardiopulmonary bypass is the most commonly used means of artificial circulation in cardiac surgery. However, it suffers from the effects of haemodilution and activation of inflammatory/coagulation cascades. Prime displacement (PD) can offset haemodilution and mini-extracorporeal technology (MIECT) can offset both. So far, no study has compared all of these modalities together; hence, we compared the outcomes of these 3 modalities at our institution. METHODS: This was a retrospective analysis of our cardiac surgical database. A total of 9626 patients underwent conventional bypass (CB), 3125 patients underwent a modification of CB, called PD, and 904 underwent MIECT. A 1:1 propensity-matching algorithm was employed using IBM SPSS 24 to match (i) 813 MIECT patients with 813 CB patients and (ii) 717 MIECT patients with 717 PD patients. The patients included coronary artery bypass grafting and valve surgery. RESULTS: MIECT had significantly (P < 0.05) longer bypass and cross-clamp times compared to CB and PD. MIECT had significantly higher rates of postoperative atrial fibrillation associated with it compared to CB. The mean red cell blood transfusion was significantly lower in the MIECT group compared to the CB group as was the mean platelet transfusion and fresh frozen plasma transfusion. The overall 5-year survival was higher in the MIECT group compared to the CB group (log-rank, P = 0.018). Between the MIECT and the PD groups, we found the incidence of renal failure and gastrointestinal complications to be significantly higher in the PD group compared to the MIECT group. CONCLUSIONS: MIECT has short-term advantages over CB and PD. However, due to the retrospective limitations of the study, including calendar time bias, a multicentre randomized controlled trial comparing all 3 modalities will be beneficial for the larger cardiac community.

Antegrade rapid prime displacement in elective coronary artery surgery is associated with lower perioperative blood transfusions and a shorter hospital stay.

OBJECTIVES: Haemodilution during cardiopulmonary bypass is associated with increased perioperative blood transfusions and is thought to reduce intraoperative oxygen delivery to the brain. We sought to evaluate our method of rapid antegrade prime displacement in the context of the perioperative blood transfusion rate, intraoperative cerebral saturations and postoperative hospital stay. METHODS: Retrospective analysis of 160 propensity-matched patients undergoing elective coronary artery bypass grafting was performed comparing different perfusion strategies on perioperative blood transfusion and length of postoperative stay. Eighty patients who had rapid antegrade prime displacement and vacuum-assisted venous drainage (RAD-VAD) were compared with 80 patients who had conventional cardiopulmonary bypass with gravity drainage (CB). RAD-VAD involved displacing all or most of the prime in the circuit with the patient's own blood prior to the initiation of cardiopulmonary bypass within a 15-20 s window. Within each group, 10 patients had intraoperative cerebral saturation measurements. RESULTS: There were no differences in the baseline characteristics between the groups. Both groups had a significant fall (P < 0.05) in haematocrit during cardiopulmonary bypass from preoperative values, however, the fall in haematocrit was significantly less in the RAD-VAD group (P < 0.05). There was significantly (P < 0.05) less intraoperative and postoperative homologous blood transfusions in the RAD-VAD group (47.892 ml ± 8.14 and 76.58 ml ± 21.58) compared with the CB group (229.06 ml ± 105.03 and 199.91 ml ± 47.13). There was a significant fall in cerebral saturations within both groups (P < 0.05) but it was not significant between the groups. The postoperative stay was significantly (P < 0.05) shorter in the RAD-VAD group compared with the conventional group (7.74 days ± 0.51 vs 10.13 days ± 0.95). CONCLUSIONS: RAD-VAD is associated with a significantly lower blood transfusion rate perioperatively and shorter hospital stays compared with CB.