Aldea G S, Doursounian M, O'Gara P, Treanor P, Shapira O M, Lazar H L, Shemin R J
Department of Cardiothoracic Surgery, Boston University Medical Center, Massachusetts 02118-2393, USA.
Ann Thorac Surg. 1996 Aug;62(2):410-7; discussion 417-8.
A substantial proportion of patients undergoing primary coronary revascularization require homologous transfusions. To address this problem, a comprehensive strategy to diminish perioperative blood loss was developed.
A prospective randomized trial was undertaken to test the hypothesis that "tip-to-tip" heparin-bonded cardiopulmonary bypass circuits (HBC) can further enhance blood conservation and clinical outcomes in patients undergoing primary coronary artery bypass grafting. Two hundred thirty-four patients were treated with either HBC and lower anticoagulation therapy (activated clotting time > 280 seconds) or with conventional, nonheparin-bonded circuits and full anticoagulation therapy (activated clotting time > 480 seconds).
Preoperative and intraoperative risk profiles and characteristics were similar in both groups, with 69.7% of the patients undergoing nonelective coronary artery bypass grafting. Compared with the group with nonheparin-bonded circuits, patients treated with HBC had a lower chest tube output in the first 24 hours (561 +/- 257 versus 651 +/- 403; p = 0.04), were less likely to receive blood products (31.6% versus 47.9%; p = 0.01), and required substantially fewer homologous donor units (1.98 +/- 4.8 versus 4.29 +/- 10.1; p = 0.029). Patients treated with HBC required a shorter duration of ventilatory support (13.2 +/- 16.9 versus 23.4 +/- 50.0 hours; p = 0.04), spent less time in the surgical intensive care unit (20.7 +/- 17.4 versus 35.5 +/- 61.7 hours; p = 0.01), spent fewer days in the hospital (6.0 +/- 2.5 versus 7.3 +/- 5.2 days; p = 0.02), and had fewer postoperative complications (25.6% versus 39.3%; p = 0.03). The use of HBC with a lower anticoagulation protocol was not associated with any adverse events.
This study demonstrates that the use of HBC with a lower anticoagulation protocol in primary coronary artery bypass grafting safely and effectively reduces the incidence and magnitude of homologous transfusion, the duration of ventilation, and surgical intensive care unit and hospital stays.
相当一部分接受初次冠状动脉血运重建的患者需要同种输血。为解决这一问题，制定了一项减少围手术期失血的综合策略。
进行了一项前瞻性随机试验，以检验“端对端”肝素涂层体外循环回路（HBC）能否进一步提高接受初次冠状动脉搭桥术患者的血液保护效果和临床结局这一假设。234例患者分别接受HBC加较低抗凝治疗（活化凝血时间>280秒）或传统的非肝素涂层回路加全量抗凝治疗（活化凝血时间>480秒）。
两组患者术前和术中的风险概况及特征相似，69.7%的患者接受了非选择性冠状动脉搭桥术。与非肝素涂层回路组相比，接受HBC治疗的患者术后24小时胸腔引流管引流量更低（561±257对651±403；p=0.04）；接受血制品输血的可能性更小（31.6%对47.9%；p=0.01），所需的同种供体单位显著更少（1.98±4.8对4.29±10.1；p=0.029）。接受HBC治疗的患者需要的通气支持时间更短（13.2±16.9对23.4±50.0小时；p=0.04），在外科重症监护病房的时间更短（20.7±17.4对35.5±61.7小时；p=0.01），住院天数更少（6.0±2.5对7.3±5.2天；p=0.02），术后并发症更少（25.6%对39.3%；p=0.03）。使用HBC并采用较低抗凝方案未出现任何不良事件。
本研究表明，在初次冠状动脉搭桥术中使用HBC并采用较低抗凝方案可安全有效地降低同种输血的发生率和输血量、缩短通气时间以及减少在外科重症监护病房和医院的住院时间。
