Stammers Alfred H, Tesdahl Eric A, Mongero Linda B, Stasko Andrew
SpecialtyCare, Nashville, TN, USA.
Perfusion. 2018 Nov;33(8):638-648. doi: 10.1177/0267659118777199. Epub 2018 Jun 6.
Myocardial protection is performed using diverse cardioplegic (CP) solutions with various combinations of chemical and blood constituents. Newer CP formulations that extend ischemic intervals may require greater asanguineous volume, contributing to hemodilution.
We evaluated intraoperative hemodilution and red blood cell (RBC) transfusion rates among three common CP solutions during cardiac valve surgery. Data from 5,830 adult cardiac primary valve procedures where either four-to-one blood CP (4:1), del Nido solution (DN) or microplegia (MP) was used at 173 United States surgical centers. The primary outcome was the nadir hematocrit (Hct) during cardiopulmonary bypass (CPB), with a secondary outcome of total units of RBC transfused intraoperatively. Outcomes were assessed using mixed-effects regression, with controls for patient size, age, first Hct in the operating room, ultrafiltration volume, net bypass circuit priming volume, anesthesia and perfusion asanguineous volumes, cross-clamp and total procedure times, procedure type, reoperation, hospital, surgeon and twelve other patient and procedural variables.
A total of 2,641 patients received 4:1 (45.3%), 1,864 received DN (32.0%) and 1,325 received MP (22.7%). There were only slight differences in the central tendency (mean (SD)) for crude nadir Hct on CPB: 4:1, 25.5 (4.5), DN, 26.0 (4.6) and MP, 26.5 (4.7). After controlling for numerous operative and patient characteristics, the regression-adjusted estimate of the nadir Hct on CPB for MP was 26.2%, compared to 25.7% for 4:1 and 25.7% for DN; differences between MP and the other methods were statistically significant (p<0.01). Unadjusted mean RBC units transfused per patient was very similar across the groups (4:1, 2.2; MP, 2.3; DN, 2.4). Regression-adjusted estimates for the number of units of RBC transfused intraoperatively showed no statistically significant differences between CP methods.
In patients undergoing cardiac valve surgery, the type of CP did not have a strong clinical impact on hemodilution or transfusion. Choice of a myocardial preservation solution can be made independently of its effect on intraoperative Hct.
心肌保护通过使用含有不同化学和血液成分组合的多种心脏停搏液（CP）来实现。能延长缺血间隔时间的新型CP配方可能需要更大的无血容量，从而导致血液稀释。
我们评估了心脏瓣膜手术中三种常见CP溶液的术中血液稀释和红细胞（RBC）输血率。数据来自美国173个手术中心的5830例成人心脏原发性瓣膜手术，这些手术使用了四比一血液CP（4:1）、德尔尼多溶液（DN）或微停搏液（MP）。主要结局是体外循环（CPB）期间的最低血细胞比容（Hct），次要结局是术中输注RBC的总单位数。使用混合效应回归评估结局，控制患者体型、年龄、手术室初始Hct、超滤量、体外循环回路净预充量、麻醉和灌注无血容量、交叉夹闭和总手术时间、手术类型、再次手术、医院、外科医生以及其他十二个患者和手术变量。
共有2641例患者接受4:1（45.3%），1864例接受DN（32.0%），1325例接受MP（22.7%）。CPB时粗最低Hct的集中趋势（均值（标准差））仅有轻微差异：4:1为25.5（4.5），DN为26.0（4.6），MP为26.5（4.7）。在控制了众多手术和患者特征后，MP在CPB时最低Hct的回归调整估计值为26.2%，4:1为25.7%，DN为25.7%；MP与其他方法之间的差异具有统计学意义（p<0.01）。各组间未调整的每位患者平均输注RBC单位数非常相似（4:1为2.2；MP为2.3；DN为2.4）。术中输注RBC单位数的回归调整估计值显示CP方法之间无统计学显著差异。
在接受心脏瓣膜手术的患者中，CP的类型对血液稀释或输血没有强烈的临床影响。心肌保护溶液的选择可以独立于其对术中Hct的影响来进行。
