Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study☆

Abstract

To evaluate the clinical results of aortic valve replacement performed with a miniaturized closed circuit extracorporeal circulation (MECC) system and to compare it to standard cardiopulmonary bypass (CPB). One hundred and twenty consecutive patients undergoing isolated aortic valve replacement were randomly assigned to either a miniaturized closed circuit CPB with the maquet-cardiopulmonary MECC System (study group, n=60) or to a standard CPB (control group, n=60). Demographic characteristic and operative data were similar in the two groups. No hospital death occurred in either group and no difference in intensive care unit (ICU) stay and in-hospital stay was observed. Patients in the study group showed lower chest tube drainage (212+/-62 ml vs. 420+/-219 ml, P<0.05) and lower need for blood products (6.1% vs. 40.4%, P<0.05) than patients in the control group. Platelet count at ICU arrival was significantly higher in the study group (139+/-40 x 10(9)/l vs. 164+/-75 x 10(9)/l, P=0.05). Peak postoperative troponin I release was significantly lower in the MECC group (3.81+/-2.7 ng/dl vs. 6.6+/-6.8 ng/dl, P<0.05). In this randomized study the MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage as compared to standard CPB.

A prospective randomised multicentre clinical comparison of a minimised perfusion circuit versus conventional cardiopulmonary bypass☆☆☆

“…Minimised bypass circuits have also been linked to a better myocardial protection, mainly relying on the lower postoperative release of myocardial injury markers [6][7][8][9]19]. We have demonstrated similar results in the ROCsafeRX TM study group with significantly lower levels of creatine kinase (CK), CK-MB and Troponine I during the postoperative course.…”

“…A positive association between the lowest haematocrit during bypass and organ dysfunction [5,17], in-hospital morbidity and mortality [13,14] has also been described. Modern perfusion concepts, including retrograde autologous priming, lowvolume blood cardioplegia and normothermic perfusion in addition to the low priming volumes of miniperfusion circuits, have resulted in a significant reduction of haemodilution [2,[5][6][7][8][9][10]. In accordance, patients in the MPC group showed a significantly lower drop in haematocrit that persisted up to 6 h, postoperatively.…”

“…Although the positive impact of MPC has been shown in terms of transfusion requirement [5,6,[8][9][10]20], myocardial protection [6][7][8][9]19,20], reduction of platelet consumption [6,8,9] and inflammatory response [2,5,6,21], an overall clinical benefit has been lacking in most publications [2,5,7,9,22,23]. Likewise, with the exception of myocardial infarction, analysis of the postoperative course, including the incidence of major adverse events defined as mortality, major cerebrovascular accidents (four cases of transient postoperative delirium in each group) and re-operation as well as the freedom from adverse events as a whole, has shown no advantage of one bypass circuit over the other.…”

“…At the same time, prospective randomised comparisons with adequate patient numbers are lacking. To date, only five such studies with a group size of 50 patients or more have been published [6][7][8][9][10].…”

Fast track in cardiac surgery

“…Dazu wurde die komplette Sternotomie zu einer Teilsternotomie modifiziert. Gleichzeitig kamen die oben beschriebenen miniaturisierten extrakorporalen Zirkulationen zum Einsatz[1]. Dies sind aktuelle Entwicklungen, die bei einem konventionellen Aortenklappenersatz die Möglichkeiten von Fast-TrackKonzepten neu eröffnen und gegenüber den bisherigen Verfahren weiter verbesserte Voraussetzungen schaffen.…”