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Letters to the Editor |
Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
Received 3 December 2007; accepted 7 February 2008.
* Corresponding author. Tel.: +44 113 392 6901; fax: +44 113 392 6657. (Email: JoeMcGoldrick{at}doctors.org.uk).
Key Words: Coronary artery surgery • Surgical sealants • Myocardial infarction
Lamm et al. [1] conclude ‘the intraoperative use of fibrin sealant posed an increased risk of myocardial damage or death after coronary artery surgery’. The paper is thought provoking and flawed.
Lamm reports high mortality rates in both study groups. Groups were biased regarding patient age, cross-clamp time, and concomitant aortic/carotid surgery. What valid comparison can be drawn when one group has twice as many extended cross-clamp times? Longer cross-clamp/bypass times may reflect greater technical complexity or even surgical misadventure; scenarios guaranteeing higher morbidity and haemorrhage. Surgical sealant may predict, but not cause surgical mortality.
Our results contrast markedly with the Munich experience (the author using Tisseel® Sealant since 1986 in complex cardiac and aortic cases, and in all cases including CABGs since May 2002). Part of a broader study, we mention our CABG sealant experience (single surgeon to avoid bias) for two matched CABG groups for a period of five years before and after ‘routine’ sealant administration. Our results may inform this debate.
We apply a fine spray of Tisseel® (Tissucol® equivalent) as a prophylactic adjunct during cardiopulmonary bypass (CPB) to coronary anastomoses. Forty-five percent of our CABG cases were urgent/emergent (post-thrombolysis, aspirin, clopidogrel, etc.), and thus ‘pre-selected’ to bleed. The mortality was low in both groups, which were matched for age, sex, risk factors and isolated coronary surgery.
Blood loss 12 h postoperatively (Tisseel® group) was >35% lower, total blood loss 30% lower, and mediastinal drains were removed earlier. Blood transfusion rates fell by 45%, the amount transfused fell >60%. In those receiving a blood transfusion, the number of transfused units was >45% lower in the sealant group, with a dramatic fall in platelet/FFP use. Re-exploration rates were <1% in both groups.
We have found no evidence of increase in graft thrombosis, morbidity or mortality associated with sealant use. Rather than creating a prothrombotic phenomenon as in Munich, our use of Thrombelastography® showed sealant CABG patients exhibited less hypercoagulability than groups where no sealant was used.
Lamm states ‘the use of fibrin sealants in aortocoronary procedures should be restricted to treatment of otherwise not controllable bleeding’; a conclusion unsupported by their methodology or results. This is not, in our opinion, how sealants should be effectively used, but reserved for prophylaxis, difficult access bleeding or coagulopathy.
As more patients are receiving anti-platelet agents, operated urgently, or have bleeding diatheses, we advocate expansion of sealant use, not restriction. It is in achieving surgical haemostasis that fibrin sealants continue to exhibit their clinical pedigree; they may indeed ‘cast out the devil’.
References
This article has been cited by other articles:
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  P. Lamm, G. Juchem, and B. Reichart Reply to McGoldrick and White. Eur. J. Cardiothorac. Surg., May 1, 2008; 33(5): 950 - 950. [Full Text] [PDF]
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