Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation
Restricted accessResearch articleFirst published online March, 2024
Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation
Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion.
Methods
Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018.
Results
A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5–15), a weight of 32 kg (IQR, 16–55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6–14.9), and preoperative hematocrit of 40.4% (IQR, 37.2–44.3). Median CPB time was 81.5 min (IQR, 58–125), and median hematocrit coming off CPB was 26% (IQR, 23–29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001).
Conclusions
Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays.
TsangVTMullalyRJRaggPG, et al.Bloodless open-heart surgery in infants and children. Perfusion1994; 9(4): 257–263.
2.
OttDACooleyDA. Cardiovascular surgery in Jehovah’s Witnesses. Report of 542 operations without blood transfusion. JAMA1977; 238(12): 1256–1258.
3.
IstaphanousGKWheelerDSLiscoSJ, et al.Red blood cell transfusion in critically ill children: a narrative review. Pediatr Crit Care Med2011; 12(2): 174–183.
4.
KippsAKWypijDThiagarajanRR, et al.Blood transfusion is associated with prolonged duration of mechanical ventilation in infants undergoing reparative cardiac surgery. Pediatr Crit Care Med2011; 12(1): 52–56.
5.
SalvinJWScheurerMALaussenPC, et al.Blood transfusion after pediatric cardiac surgery is associated with prolonged hospital stay. Ann Thorac Surg2011; 91(1): 204–210.
6.
RedlinMBoettcherWKukuckaM, et al.Blood transfusion during versus after cardiopulmonary bypass is associated with postoperative morbidity in neonates undergoing cardiac surgery. Perfusion2014; 29(4): 327–332.
7.
MazineARached-D’AstousSDucruetT, et al.Pediatric acute lung injury and sepsis investigators network. Blood transfusions after pediatric cardiac operations: A North American multicenter prospective study. Ann Thorac Surg2015; 100(2): 671–677.
8.
IyengarAScipioneCNShethP, et al.Association of complications with blood transfusions in pediatric cardiac surgery patients. Ann Thorac Surg2013; 96(3): 910–916.
9.
SzékelyACserépZSápiE, et al.Risks and predictors of blood transfusion in pediatric patients undergoing open heart operations. Ann Thorac Surg2009; 87(1): 187–197.
10.
KarimiMFlorentino-PinedaIWeatherredT, et al.Blood conservation operations in pediatric cardiac patients: a paradigm shift of blood use. Ann Thorac Surg2013; 95(3): 962–967.
11.
KwakJGParkMLeeJ, et al.Multiple approaches to minimize transfusions for pediatric patients in open-heart surgery. Pediatr Cardiol2016; 37(1): 44–49.
12.
OlshoveVFJrPrestonTGomezD, et al.Perfusion techniques toward bloodless pediatric open heart surgery. J Extra Corpor Technol2010; 42(2): 122–127.
13.
DurandyY.Perfusionist strategies for blood conservation in pediatric cardiac surgery. World J Cardiol2010; 2(2): 27–33.
14.
AnastasiadisKMurkinJAntonitsisP, et al.Use of minimal invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies international Society (MiECTiS). Interact Cardiovasc Thorac Surg2016; 22(5): 647–662.
15.
WhitneyGDavesSHughesA, et al.Implementation of a transfusion algorithm to reduce blood product utilization in pediatric cardiac surgery. Paediatr Anaesth2013; 23(7): 639–646.
16.
BudakABMcCuskerKGunaydinS. A structured blood conservation program in pediatric cardiac surgery. Eur Rev Med Pharmacol Sci2017; 21(5): 1074–1079.
17.
GaiesMGGurneyJGYenAH, et al.Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med2010; 11(2): 234–238.
18.
WillemsAHarringtonKLacroixJ, et al.Comparison of two red-cell transfusion strategies after pediatric cardiac surgery: a subgroup analysis. Crit Care Med2010; 38(2): 649–656.
19.
OjitoJWHannanRLMiyajiK, et al.Assisted venous drainage cardiopulmonary bypass in congenital heart surgery. Ann Thorac Surg2001; 71(4): 1267–1271.
20.
De SomerFMulhollandJWBryanMR, et al.O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury: time for a goal-directed perfusion management?Crit Care2011; 15(4): 1–1.
21.
RanucciMJohnsonIWillcoxT, et al.Goal-directed perfusion to reduce acute kidney injury: a randomized trial. J Thorac Cardiovasc Surg2018; 156(5): 1918–1927.
22.
OldeenMEAngonaREHodgeA, et al.American society of extracorporeal technology: development of standards and guidelines for pediatric and congenital perfusion practice. World J Pediatr Congenit Heart Surg2019; 12(1): 84–92.
23.
AndoMTakahashiYSuzukiN. Open heart surgery for small children without homologous blood transfusion by using remote pump head system. Ann Thorac Surg2004; 78(5): 1717–1722.
24.
MiyajiKKohiraSMiyamotoT, et al.Pediatric cardiac surgery without homologous blood transfusion, using a miniaturized bypass system in infants with lower body weight. J Thorac Cardiovasc Surg2007; 134(2): 284–289.
25.
BoettcherWSinzobahamvyaNMieraO, et al.Routine application of bloodless priming in neonatal cardiopulmonary bypass: a 3 year experience. Pediatr Cardiol2017; 38(4): 807–812.
26.
NathanMTishlerBGauvreauK, et al.A red cell preservation strategy reduces postoperative transfusions in pediatric heart surgery patients. Paediatr Anaesth2018; 28(5): 450–457.
27.
MatteGSPedroJ. History and use of del Nido cardioplegia solution at Boston Children’s Hospital. J Extra Corpor Technol2012; 44(3): 98.
28.
DurandyYHulinS. Intermittent warm blood cardioplegia in the surgical treatment of congenital heart disease: clinical experience with 1400 cases. J Thorac Cardiovasc Surg2007; 133(1): 241–246.
29.
KotaniYHonjoONakakuraM, et al.Single center experience with a low volume priming cardiopulmonary bypass circuit for preventing blood transfusion in infants and small children. ASAIO J2009; 55(3): 296–299.
30.
RedlinMKukuckaMBoettcherW, et al.Blood transfusion determines postoperative morbidity in pediatric cardiac surgery applying a comprehensive blood-sparing approach. J Thorac Cardiovasc Surg2013; 146(3): 537–542.
31.
WuTLiuJWangQ, et al.Superior blood-saving effect and postoperative recovery of comprehensive blood-saving strategy in infants undergoing open heart surgery under cardiopulmonary bypass. Medicine (Baltimore)2018; 97(27): e11248.
32.
BoettcherWRedlinMDehmelF, et al.Asanguineous priming of miniaturized paediatric cardiopulmonary bypass circuits for congenital heart surgery: independent predictors associated with transfusion requirements and effects on postoperative morbidity. Eur J Cardiothorac Surg2018; 53(5): 1075–1081.
33.
KadnerAHeinischPPBartkevicsM, et al.Initial experiences with a centrifugal-pump based minimal invasive extracorporeal circulation system in pediatric congenital cardiac surgery. J Thorac Dis2019; 11(Suppl 10): S1446.
34.
KarimiMSullivanJMLererT, et al.National trends and variability in blood utilization in paediatric cardiac surgery. Interact Cardiovasc Thorac Surg2017; 24(6): 938–943.
35.
KarthaVMJacobsJPVenerDF, et al.National benchmarks for proportions of patients receiving blood transfusions during pediatric and congenital heart surgery: an analysis of the STS congenital heart surgery database. Ann Thorac Surg2018; 106(4): 1197–1203.
36.
CholetteJMRubensteinJSAlfierisGM, et al.Children with single-ventricle physiology do not benefit from higher hemoglobin levels post cavopulmonary connection: results of a prospective, randomized, controlled trial of a restrictive versus liberal red-cell transfusion strategy. Pediatr Crit Care Med2011; 12(1): 39–45.
37.
de Gast-BakkerDHde WildeRBHazekampMG, et al.Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial. Intensive Care Med2013; 39(11): 2011–2019.
38.
CholetteJMSwartzMFRubensteinJ, et al.Outcomes Using a Conservative Versus Liberal Red Blood Cell Transfusion Strategy in Infants Requiring Cardiac Operation. Ann Thorac Surg2017; 103(1): 206–214.
39.
DoctorACholetteJMRemyKE, et al.Recommendations on RBC transfusion in general critically ill children based on hemoglobin and/or physiologic thresholds from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med2018; 19(9S Suppl 1): S98–S113.
40.
WypijDJonasRABellingerDC, et al.The effect of hematocrit during hypothermic cardiopulmonary bypass in infant heart surgery: results from the combined Boston hematocrit trials. J Thorac Cardiovasc Surg2008; 135(2): 355–360.
