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Eur J Cardiothorac Surg 2001;20:1078
© 2001 Elsevier Science NL

Letter to the Editor

Coronary artery bypass grafting surgery without the routine application of blood products: is it feasible?

P.R. Belcher, E.W. Muriithi

University Department of Cardiac Surgery, The Royal Infirmary, 10 Alexandra Parade, Glasgow, Scotland, G31 2ER, UK

Received 3 July 2001; accepted 20 July 2001.

Corresponding author
e-mail: pbelcher{at}clinmed.gla.ac.uk

This study [1] revisits old territory. Operations upon Jehovah's witnesses until recently had to be performed without the use of blood products and there is an extensive literature relating to this particular problem [2], and blood saving manoeuvres in general [3,4]. It is hard to understand how the authors can state that ‘Fresh frozen plasma (FFP) substitution is currently standard practice in cardiac surgery’. Don't they just mean their own unit? Because it is certainly not standard in the UK or USA.

It was interesting that they used hydroxyethyl starch as their control volume expander. I [5], among others [6,7], was able to show that hetastarch-treated patients had the same mediastinal blood loss as albumin-treated patients. Therefore it is hard to follow why Wilhelmi et al. carried out a trial of a treatment already demonstrated to be ineffective in two studies cited by the authors. Bélisle and Hardy, in their careful review of the literature until 1996 concluded that transfusion practice remained institution-dependent rather than guided by an appreciation of the literature [8]. As the authors earliest cited article was from 1985 we consider that their study was incompletely researched.

Another point of issue is the uncritical statement that FFP has been used routinely to counteract platelet dysfunction. In the articles cited there is no evidence for this assertion and on pathophysiological grounds there is no basis for connecting FFP with the platelet defect associated with cardiopulmonary bypass. This we, among others, have defined as the failure to form large stable aggregates (macroaggregation) while the formation of small aggregates (microaggregation) is unaffected [9–11]. We have also shown that this is a consequence of heparinisation and that the influence of extracorporeal circulation is limited [12].

Is it feasible? It certainly is and has been so for 35 years.

References

  1. Wilhelmi M., Franke U., Cohnert T., Weber P., Kaukemüller J., Fischer S., Wahlers T., Haverich A. Coronary artery bypass grafting surgery without the routine application of blood products: is it feasible?. Eur J Cardio-thorac Surg 2001(19):657-661.
  2. Sandiford F.M., Chiariello L., Hallman G.L., Cooley D.A. Aorto–coronary bypass in Jehovah's witnesses. J Thorac Cardiovasc Surg 1974;68:1-7.[Medline]
  3. Cooley D.A., Bloodwell R.D., Beall A.C., Hallman G.L. Cardiac valve replacement without blood transfusion. Am J Surg 1966;112:743-751.[Medline]
  4. Zubiate P., Kay J.H., Mendez A.M., Krohn B.G., Hochman R., Dunne E.F. Coronary artery surgery — a new technique with use of little blood if any. J Thorac Cardiovasc Surg 1974;68:263-267.[Medline]
  5. Belcher P., Lennox S.C. Avoidance of blood transfusion in coronary artery surgery: a trial of hydroxyethyl starch. Ann Thorac Surg 1984;37:365-370.[Abstract]
  6. Diehl J.T., Lester J.L., Cosgrove D.M. Clinical comparison of hetastarch and albumin in postoperative cardiac patients. Ann Thorac Surg 1982;34:674.[Abstract]
  7. Kirklin J.K., Lell W.A., Kouchoukos N.T. Hydroxyethyl starch versus albumin for colloid infusion following cardiopulmonary bypass in patients undergoing myocardial revascularization. Ann Thorac Surg 1984;37:40.[Abstract]
  8. Bélisle S., Hardy J.F. Hemorrhage and the use of blood products after adult cardiac operations: myths and realities. Ann Thorac Surg 1996;62:1908-1917.[Abstract/Free Full Text]
  9. Menys V.C., Belcher P.R., Noble M.I.M., Evans R.D., Drossos G.E., Pillai R., Westaby S. macroaggregation of platelets in plasma, as distinct from microaggregation in whole blood (and plasma), as determined using optical aggregometry and platelet counting respectively, is specifically impaired following cardiopulmonary bypass in man. Thromb Haemost 1994;72:511-518.[Medline]
  10. Belcher P.R., Muriithi E.W., Milne E.M., Wanikiat P., Wheatley D.J., Armstrong R.A. Heparin, platelet aggregation, neutrophils and cardiopulmonary bypass. Thromb Res 2000;98:249-256.[Medline]
  11. Kawahito K., Kobayashi E., Iwasa H., Misawa Y., Fuse K. Platelet aggregation during cardiopulmonary bypass evaluated by a laser light-scattering method. Ann Thorac Surg 1999:79-84.
  12. Muriithi E.W., Belcher P.R., Rao J.N., Chaudhry M.A., Nicol D., Wheatley D.J. The effect of heparin and extracorporeal circulation on platelet counts and platelet microaggregation during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2000;120:538-543.[Abstract/Free Full Text]




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