Minimized perfusion circuits: an alternative in the surgical treatment of Jehovah's Witnesses.

OBJECTIVES: Jehovah's Witnesses present a challenge to cardiac surgeons, as quality of care is not only defined by mortality and morbidity, but also by the avoidance of blood transfusions. Over the last years, minimized perfusion circuits (MPC) have contributed substantially to the achievement of this goal in our clinic. Presented is a retrospective analysis of our experience. METHODS: Twenty-nine Jehovah's Witnesses, aged 69 ± 10 years, have undergone cardiac surgery with a MPC in our institution since 2005. The ROCsafe (reservoir optional circuit) MPC was used in most of these patients (n=27) as it offers the unique possibility of a speedy integration of a reservoir in the event of a major air leak, thereby, negligating any safety concerns. RESULTS: There was no in-hospital or 30-day postoperative mortality. Mean ICU stay was 1.6 ± 2 days with a mean intubation time of 11.3 ± 9.1 hrs. Postoperative complications included one myocardial infarction with accompanying low cardiac output, one stroke, one transient delirium, one idiopathic thrombocytopenia and three re-operations (one sternal infection, one postoperative bleeding and one delayed tamponade). The mean postoperative hospital stay was 9.9 ± 2.3 days. Mean decrease in hemoglobin was 2.1 ± 1.3 g/dl during cardiopulmonary bypass and 3.4 ±1.4 g/dl at discharge. The lowest postoperative hemoglobin level was 9.3 ±1.8 (Range 6-12.9). CONCLUSIONS: These encouraging results emphasize the role MPCs can play in optimizing the quality of patient care. We hope that this report can serve as a stimulus for similar experiences.

State of the art in cardiovascular perfusion: now and in the next decade.

The development and improvement of cardiopulmonary bypass technology is an ongoing process. During the past decade, a number of publications on improvements and best practices have appeared, especially in the areas of biocompatibility, materials sciences, instrumentation, monitoring of physiological parameters and knowledge base (education and evidence-based medicine). Biocompatibility may be defined not only as an inherent property of a particular composition of matter, but also as a set of properties concerning shape, finish, fabrication techniques and choice of application. Materials in use for cardiopulmonary bypass have changed and coated components have been used frequently. Improvements in the area of instrumentation were achieved by adaptation of conventional cardiopulmonary bypass circuits. Miniaturization and re-design of cardiopulmonary bypass circuits (so-called minimized perfusion circuits or minimal extracorporeal circulation circuits) have made cardiopulmonary bypass technology less traumatic. A team approach, including the cardiac surgeon, the anesthesiologist and the cardiovascular perfusionist, was deemed beneficial in order to achieve further improvements. Next to choice of technology and material for a given operation, adjunct measures such as pharmaceutical treatment and blood conservation strategies need to be taken into consideration. Monitoring of variables during cardiopulmonary bypass has made some progress, while the knowledge base has expanded due to studies on best practices. For the immediate future, sound scientific knowledge and intelligent monitoring tools will allow cardiopulmonary bypass to be tailored to individual patients' needs.

Are minimized perfusion circuits the better heart lung machines? Final results of a prospective randomized multicentre study.

INTRODUCTION: Minimized perfusion circuits (MPCs), although aiming at minimizing the adverse effects of cardiopulmonary bypass, have not yet gained popularity. This can be attributed to concerns regarding their safety, as well as lack of sufficient evidence of their benefit. METHODS: Described is a randomized, multicentre study comparing the MPC - ROCsafeRX to standard cardiopulmonary bypass in patients undergoing elective coronary artery bypass grafting and/ or aortic valve replacement. RESULTS: Five hundred patients were included in the study (252 randomized to the ROCsafeRX group and 248 to standard cardiopulmonary bypass). Both groups were well matched for demographic characteristics and type of surgery. No operative mortality and no device-related complications were encountered. Transfusion requirement (333 ± 603 vs. 587 ± 1010 ml; p=0.001), incidence of atrial fibrillation (16.3% vs. 24.2%; p=0.03) and the incidence of major adverse events (9.1% vs. 16.5%; p=0.02) were all in favour of the MPC group. CONCLUSION: These results confirm both the safety and efficacy of the ROCsafeRX MPC for a large variety of cardiac patients. Minimized perfusion circuits should, therefore, play a greater role in daily practice so that as many patients as possible can benefit from their advantages.

Beneficial effects of modern perfusion concepts in aortic valve and aortic root surgery.

Minimized perfusion circuits (MPC) were found to reduce side effects of standard extracorporeal circulation (ECC). We evaluated the safety and efficacy of the ROCsafe MPC for aortic valve and aortic root surgery. One hundred and seventy patients were randomized for surgery using either MPC [n = 85, 30 female/55 male, mean age: 69.8 +/- 11.8 years; aortic valve replacement (AVR): n = 40; AVR + coronary artery bypass graft (CABG): n = 31; David operation: n = 3; aortic root replacement (ARR): n = 11] or ECC [n = 85, 29 female/56 male, mean age: 67.7 +/- 9.5 years; AVR: n = 39; AVR+CABG: n = 35, David operation: n = 2; ARR: n = 9]. Neurological status, length of ICU stay, C-reactive protein (CRP), blood count, transfusion requirements and bleeding volume were analyzed. The MPC system provided ultrasound-controlled de-airing. A small roller pump and a flexible reservoir were used for left ventricular venting. As a control, we used a standard ECC with cardiotomy suction and hard-shell reservoir. Cross-clamp time (MPC: 76.5 +/- 29.5; ECC: 79.0 +/- 34.0 min) and bypass time (MPC: 103.0 +/- 37.9; ECC: 106.9 +/- 44.9 min) were comparable between groups. Transfusion requirements (red blood cells: MPC: 1.5 +/- 1.5 vs. ECC: 2.2 +/- 2.1 units [p = 0.05], frozen plasma: MPC: 1.2 +/- 1.8 vs. ECC: 1.9 +/- 2.4 units [p = 0.03]), postoperative bleeding (MPC: 521 +/- 283 vs. ECC: 615 +/- 326 ml/24 h, p = 0.09) were lower using MPC. ICU stay was shorter with MPC (1.6 +/- 1.6 days) compared to ECC (2.4 +/- 2.8 days, p = 0.001). One stroke occurred in each group. The ROCsafe MPC provides safe circulatory support for a wide range of aortic valve surgeries. Transfusion requirements, postoperative bleeding and length of ICU stay were markedly reduced compared to standard extracorporeal perfusion.

[Vacuum assisted closure for the treatment of sternal wound infections -- rapid infection control and bridging to reconstructive surgery]. / Vakuumtherapie bei sternaler Wundinfektion -- Initiale Therapie zur Infektkontrolle und Uberbrückung zur plastisch chirurgischen Rekonstruktion.

Vacuum Assisted Closure (V.A.C.) is a sound strategy to control severe post-sternotomy infection. Secondary re-wiring of the sternal bone or reconstructive surgery may be required later to achieve complete wound closure. Ten patients with severe sternal bone infection underwent initial V.A.C. therapy and delayed surgery for wound closure. Complete wound healing was achieved in all cases. As a case report we describe a patient with right-sided mastectomy and irradiation for breast cancer, who developed severe post-sternotomy infection and sternal bone necrosis following CABG. A combination of V.A.C. therapy and surgical reconstruction using a pedicled latissimus dorsi musculocutaneous flap led to complete wound closure.