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Heparin-bonded circuits improve clinical outcomes in emergency coronary artery bypass grafting
G S Aldea1, K Lilly, J M Gaudiani
1Department of Cardiothoracic Surgery, Boston Medical Center, Massachusetts 02118-2393, USA. galdea@bu.edu
Insights
Heparin-bonded circuits (HBC) with a lower anticoagulation protocol (LAP) significantly reduce complications and costs in emergency coronary artery bypass grafting (EM-CABG) patients. This approach improves outcomes compared to conventional non-heparin-bonded circuits (NHBC) with full anticoagulation.
Area of Science:
- Cardiovascular Surgery
- Medical Devices
- Critical Care Medicine
Background:
- Emergency coronary artery bypass grafting (EM-CABG) is associated with higher morbidity and mortality.
- Heparin-bonded circuits (HBC) improve outcomes in non-emergent CABG, but their benefit in EM-CABG is unclear.
- The inflammatory response and hemostasis challenges in EM-CABG require evaluation of novel circuit technologies.
Purpose of the Study:
- To evaluate the efficacy of heparin-bonded circuits (HBC) with a lower anticoagulation protocol (LAP) in emergency coronary artery bypass grafting (EM-CABG).
- To compare clinical outcomes between HBC/LAP and conventional non-heparin-bonded circuits (NHBC) with full anticoagulation protocol (FAP) in EM-CABG patients.
- To assess the impact of HBC/LAP on transfusion requirements, perioperative complications, and resource utilization in EM-CABG.
Main Methods:
- Retrospective analysis of 206 consecutive EM-CABG patients over four years (1993-1997).
- Patients were divided into two groups: NHBC with FAP (n=81) and HBC with LAP (n=125).
- Prospective collection of outcomes including transfusion needs, inotropic support, perioperative myocardial infarction (MI), pulmonary complications, and length of stay.
Main Results:
- HBC/LAP group required significantly fewer homologous donor units (4.1 vs 8.2, p=0.005).
- The HBC/LAP group had lower rates of inotropic support (18.6% vs 38.3%, p=0.005), perioperative MI (3.2% vs 12.3%, p=0.04), and pulmonary complications (4.0% vs 12.3%, p=0.04).
- HBC/LAP use resulted in fewer overall postoperative complications (12.8% vs 28.4%, p=0.01), shorter ventilatory support, ICU stay, and hospital stay, leading to reduced costs.
Conclusions:
- Heparin-bonded circuits with a lower anticoagulation protocol are effective in reducing transfusion requirements and postoperative complications in EM-CABG.
- HBC/LAP improves clinical outcomes and resource utilization, including shorter hospital stays and reduced costs, for high-risk EM-CABG patients.
- The findings support the use of HBC/LAP as a beneficial strategy for managing patients undergoing emergency coronary artery bypass grafting.
Abstract:
Compared to patients undergoing elective or urgent coronary artery bypass grafting (CABG), those undergoing emergency CABG (EM-CABG) have a higher morbidity and mortality. The use of heparin-bonded circuits (HBC) has been shown to improve clinical outcomes in nonemergent CABG patients. It is not known, however, whether the improved hemostasis and attenuation of the inflammatory response to cardiopulmonary bypass, conferred by HBC, can overcome the high incidence of comorbid risk factors in (EM-CABG) patients and improve their outcomes. A retrospective analysis of 206 consecutive patients undergoing EM-CABG over 4 years (1993-1997) at one institution was performed. Eighty-one patients were treated with conventional non-heparin-bonded circuits (NHBC) with full anticoagulation protocol (FAP, activated clotting time [ACT] > 480 sec); 125 patients were treated with HBC and a lower anticoagulation protocol (LAP, ACT > 280 seconds). Outcomes and results were collected prospectively and are presented as mean +/- SD. Preoperative risk profiles were similar in both treatment groups. Postoperatively, compared with the NHBC group, patients treated with HBC/LAP required fewer homologous donor units (4.1 +/- 10.7 vs 8.2 +/- 13.6 units, p = 0.005), were less likely to require inotropic support (18.6% vs 38.3%, p = 0.005), and had a lower incidence of perioperative myocardial infarction (MI, 3.2% vs 12.3%, p = 0.04) and pulmonary complications (4.0% vs 12.3%, p = 0.04). The use of HBC/LAP resulted in a decreased incidence of postoperative complications (12.8% vs 28.4%, p = 0.01, odds ratio 0.37 with 95% confidence interval [CI] 0.18-0.76). This resulted in a shorter duration of ventilatory support (30.5 +/- 54.0 vs 72.8 +/- 16.7 hours, p = 0.009), ICU stay (38.2 +/- 36.5 vs 91.5 +/- 68.7 hours, p = 0.009), hospital stay (8.0 +/- 7.1 vs 11.0 +/- 8.9 days, p = 0.008), and therefore cost. In conclusion, the use of HBC/LAP in EM-CABG resulted in a reduction of homologous transfusion and postoperative complications associated with decreased hospital stays and cost.