Asanguineous Cardiopulmonary Bypass in Infants: Impact on Postoperative Mortality and Morbidity

Abstract

Background We routinely start cardiopulmonary bypass (CPB) for pediatric congenital heart surgery without homologous blood, due to circuit miniaturization, and blood-saving measures. Blood transfusion is applied if hemoglobin concentration falls under 8 g/dL, or it is postponed to after coming off bypass or after operation. How this strategy impacts on postoperative mortality and morbidity, in infants weighing ≤ 7 kg? Methods Six-hundred fifteen open-heart procedures performed from January 2014 to June 2018 were selected. One-hundred sixty-three patients (26.5%) were transfused on CPB (group 1), while 452 (73.5%) patients were not transfused on CPB (group 2). Operative risk and complexity were similar in both groups. Postoperative mortality and morbidity were compared. Multiple logistic regression was used to detect factors independently associated with outcome. Results Observed mortality in nontransfused group (0.7% = 3/452) was significantly lower than expected (4.2% = 19/452): p = 0.0007, and much lower than in transfused group (6.7% = 11/163): p < 0.0001. CPB transfusion (p = 0.001) was independently associated with mortality, either acting as the sole factor or in combination with the Society of Thoracic Surgeons morbidity score (p = 0.013). Patients not transfused during CPB required less frequently vasoactive inotropic drugs (p = 0.011) and duration of their mechanical ventilation was shorter (93 ± 134 hours) than for transfused patients (142 ± 170 hours): p = 0.0003. CPB transfusion was an independent determinant factor for morbidity (p = 0.05), together with body weight (p < 0.0001), vasoactive inotropic score (p < 0.0001), CPB duration (p = 0.001), and postoperative transfusion (p = 0.009). Conclusion The strategy of transfusion-free CPB course, feasible in most patients ≤ 7kg, was associated with improved outcome. Asanguineous priming of CPB circuit should become standard, even in neonates and infants.

Cardiopulmonary Bypass Strategy to Facilitate Transfusion-Free Congenital Heart Surgery in Neonates and Infants

“…Indeed, improved postoperative morbidity in terms of shorter duration of mechanical ventilation and stay at the intensive care unit has been reported. 29,[32][33][34]60,65,67,69 The most recent publication from our institution also demonstrates reduced postoperative mortality when CPB is performed without blood transfusion. 67 In our experience, we also noted improved coagulation parameters when asanguineous strategies were realized during CPB.…”

“…29,[32][33][34]60,65,67,69 The most recent publication from our institution also demonstrates reduced postoperative mortality when CPB is performed without blood transfusion. 67 In our experience, we also noted improved coagulation parameters when asanguineous strategies were realized during CPB. This was confirmed by rotational thromboelastometry performed before coming off bypass (►Figs.…”

“…We recently reported on 452 patients with a body weight of up to 7 kg (mean: 4.7 kg; range: 2.22-7 kg) who received no transfusion during CPB. 67 Their last mean Hb value before CPB discontinuation was 9.8 AE 1.8 g/dL. Lower mortality score (according to the Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery 68 ), first chest entry, higher Hb concentration before undergoing bypass, and shorter CPB duration support transfusion-free CPB procedure.…”

“…We recently reported on 452 patients with a body weight of up to 7 kg (mean: 4.7 kg; range: 2.22-7 kg) who received no transfusion during CPB. 67 Their last mean Hb value before CPB discontinuation was 9.8 AE 1.8 g/dL.…”

Effects of cardiopulmonary bypass with low-priming volume on clinical outcomes in children undergoing congenital heart disease surgery

“…On the other hand, the increased priming volume results in significant hemodilution and leads to increase the usage of PRBCs. However, the risks and complications related to transfusions are increasing [3][4][5][6]. Transfusions are even associated with increased mortality, becoming an independent risk factor of postoperative mortality [4].…”