The Impact of a Blood Conservation Program in Complex Aortic Surgery

Recent Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists (STS/SCA) guidelines highlight the safety of blood conservation strategies in routine cardiac surgery. We evaluated the feasibility and impact of such a program in complex aortic surgery.

Between March 2010 and October 2011, 63 consecutive aortic replacement procedures were performed: aortic root (n = 17; 27%), ascending aorta (n = 15; 23.8%), aortic arch (n = 19; 30.2%), descending aorta (n = 8; 12.7%), and thoracoabdominal aorta (n = 4; 6.3%). Aortic dissections were present in 32 patients. A multidisciplinary approach to blood conservation included minimal perioperative crystalloid, small priming circuits, hemoconcentration, meticulous hemostasis, and tolerance of postoperative anemia (hemoglobin of ≥ 7mg/dL).

Operative mortality was 11.1%. Multivariate predictors of mortality were low preoperative hematocrit (HCT, P = 0.05) and endocarditis (P = 0.021). Seventy-four percent of patients required no intraoperative packed red blood cell (pRBC) transfusion. For nondissection patients, 80.6% required ≤ 1 U of intraoperatively compared to 54.3% in STS benchmark data (P < 0.0001). During the hospital stay, 24 patients (39%) received no pRBCs and 34 patients (54%) received ≤ 1 U of pRBCs. Multivariate predictors of pRBC transfusion were low preoperative HCT (P = 0.04) and cardiopulmonary bypass time (P = 0.01). Discharge hemoglobin/HCT values were 8.7/26.3 compared to preoperative 12.1/35.5 (p < 0.001). Complications were absent in 94% (32/34) of patients receiving ≤1 U compared to 59% (17/29) in patients who received ≥ 2 U (P = 0.001).

These findings demonstrate that a perioperative blood conservation management strategy can be extended to complex aortic surgery and is associated with better clinical outcomes.