Is elimination of cardiotomy suction preferable in aortic valve replacement? Assessment of perioperative coagulation, fibrinolysis and inflammation

Abstract

Objectives: Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes.

Methods: In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n = 20) or CATS (Cell-Saver group, n = 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery.

Results: Perioperative values for coagulofibrinolysis markers, such as thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-Cell-Saver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P < 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P = 0.004). There were no significant differences in the other clinical outcomes between the two groups.

Conclusions: In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. A CATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.

Keywords: Blood coagulation; Extracorporeal circulation; Fibrinolysis; Valve diseases.

Figure 1:

Perioperative changes in haematocrit and platelet counts. (A) Haematocrit; (B) platelet counts. Grey columns, period of CPB; open circles, non-Cell-Saver group; closed circles, Cell-Saver group. T1, before induction of anaesthesia; T2 and T3,10 min and 1 h after initiation of CPB, respectively; T4, 10 min after aortic declamping; T5, 5 min after protamine administration; T6, T7 and T8, 1, 3 and 6 h after termination of CPB, respectively; T9, first postoperative morning.

Figure 2:

Perioperative changes in coagulation and fibrinolysis markers. (A) Antithrombin III (AT); (B) thrombin–antithrombin III complex (TAT); (C) fibrinogen degeneration products (FDPs); (D) D-dimer; (E) plasmin-α2 plasmin inhibitor complex (PIC) and (F) plasminogen activator inhibitor-1 (PAI-1). The scales in the figures for FDPs and D-dimer are identical to allow comparison of the two markers. *P < 0.05; **P < 0.01 between non-Cell-Saver and Cell-Saver groups. Grey columns, symbols and other abbreviations are identical to those in Fig. 1.

Figure 3:

Perioperative changes in inflammation markers. (A) Interleukin (IL)-6; (B) IL-8; (C) IL-10 and (D) tumour necrosis factor (TNF)-α. Grey columns, symbols and other abbreviations are identical to those in Fig. 1.