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Retrograde autologous priming is an effective adjunct to decrease the blood transfusion rate, coping with the CPB-related haemodilution and its adverse clinical effects. A RAP volume individualized to each patient offers most benefit as part of a multidisciplinary blood conservation approach.

BACKGROUND: Viscoelastic tests (VETs) are recommended during cardiac surgery to monitor coagulation status and guide transfusion. We compared the results of two VETs, the Sonoclot Analyzer and the ROTEM Sigma. Agreement between viscoelastic tests' subdiagnoses and overall diagnosis severity was assessed. Correlations with conventional coagulation tests (CCT) and the discriminatory potential of numerical VET outputs for transfusion thresholds was determined. METHODS: Single-centre, prospective observational study in a tertiary academic centre.In fifty adult patients undergoing elective cardiac surgery, parallel Sonoclot, ROTEM and CCT analysis was performed before heparin, or after protamine or coagulation product administration. All patients completed the study, resulting in 139 data points. RESULTS:Agreement on the severity of coagulation disorders was acceptable (83%), but poor (27%) on the differentiation of the underlying causes. Correlations between ROTEM parameters and CCT were good (post-protamine: FIBTEM A5 (r 2 = 0.90 vs fibrinogen) and EXTEM-FIBTEM A5 difference (r 2 = 0.81 vs platelet count) ). Sonoclot correlated less (Clot Rate (r 2 = 0.25 vs fibrinogen) and Platelet Function (r 2 = 0.43 vs platelet count)). This was reflected in the discriminatory potential of these parameters as found by linear mixed modelling. We suggest clinically useful grey zones for VET cutoff interpretation.CONCLUSIONS: ROTEM and Sonoclot accord well on the detection of severity of coagulation dysfunction, but not on the diagnosis of the underlying cause. ROTEM correlated more closely with CCT then Sonoclot. We propose a testing strategy that could lead to a cost-effective approach to the bleeding cardiac surgery patient.

Abstract OBJECTIVES Research concerning cardiopulmonary bypass (CPB) management during minimally invasive cardiac surgery (MICS) is scarce. We investigated the effect of CPB parameters such as pump flow, haemoglobin concentration and oxygen delivery on clinical outcome and renal function in a propensity matched comparison between MICS and median sternotomy (MS) for atrioventricular valve surgery. METHODS A total of 356 patients undergoing MICS or MS for atrioventricular valve surgery between 2006 and 2017 were analysed retrospectively. Propensity score analysis matched 90 patients in the MS group with 143 in the MICS group. Logistic regression analysis was performed to investigate independent predictors of cardiac surgery-associated acute kidney injury in patients having MICS. RESULTS In MICS, CPB (142.9 ± 39.4 vs 101.0 ± 38.3 min; P < 0.001) and aortic cross-clamp duration (89.9 ± 30.6 vs 63.5 ± 23.0 min; P < 0.001) were significantly prolonged although no differences in clinical outcomes were detected. The pump flow index was lower [2.2 ± 0.2 vs 2.4 ± 0.1 l⋅(min⋅m2)−1; P < 0.001] whereas intraoperative haemoglobin levels were higher (9.25 ± 1.1 vs 8.8 ± 1.2; P = 0.004) and the nadir oxygen delivery was lower [260.8 ± 43.5 vs 273.7 ± 43.7 ml⋅(min⋅m2)−1; P = 0.029] during MICS. Regression analysis revealed that the nadir haemoglobin concentration during CPB was the sole independent predictor of cardiac surgery-associated acute kidney injury (odds ratio 0.67, 95% confidence interval 0.46–0.96; P = 0.029) in MICS but not in MS. CONCLUSIONS Specific cannulation-related issues lead to CPB management during MICS being confronted with flow restrictions because an average pump flow index ≤2.2 l/min/m2 is achieved in 40% of patients who have MICS compared to those who have a conventional MS. This study showed that increasing the haemoglobin level might be helpful to reduce the incidence of cardiac surgery-associated acute kidney injury after minimally invasive mitral valve surgery.

Background: Minimally invasive mitral valve (MV) surgery (MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcomes and effects on secondary organ functions in a propensity-matched comparison with conventional MV surgery. Methods and Results: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 233 patients were included after propensity-matching: 90 sternotomy patients and 143 MIVT patients. Endpoints focused on survival, quality of MV repair, and organ function effects through analysis of biomarkers and functional parameters. Regardless of longer cardiopulmonary bypass (sternotomy: 101(IQR33) min-MIVT:143(IQR45) min, p < .001) and cardioplegic arrest times (sternotomy: 64(IQR25) min-MIVT:90(IQR34) min, p < .001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p = .751ureum, p = .538glomerular filtration, p = .848), myocardial damage by troponine I level (sternotomy:1.8 ± 3.9 ng/ml-MIVT:1.2 ± 1.3 ng/ml, p = .438) and prolonged ventilatory support >24 h (sternotomy:5.5%-MIVT:8.4%, p = .417) were comparable. The systemic inflammatory reaction by postoperative C-reactive protein count was markedly lower for MIVT(p < .001). Increased rhadomyolysis was found after MIVT surgery, based on a significant elevation of creatinine-kinase levels