Haematic antegrade repriming to enhance recovery after cardiac surgery from the perfusionist side

Abstract

Background: New era of cardiac surgery aims to provide an enhanced postoperative recovery by the implementation of every step of the process. Thus, perfusion strategy should adopt evidence-based measures to reduce the impact of cardiopulmonary bypass (CPB). Hematic Antegrade Repriming (HAR) provides a standardized procedure combining several measures to reduce haemodilutional priming to 300 mL. Once the safety of the procedure in terms of embolic release has been proven, the evaluation of its beneficial effects in terms of transfusion and ICU stay should be assessed to determine if could be considered for inclusion in Enhanced Recovery After Cardiac Surgery (ERACS) programs. Methods: Two retrospective and non-randomized cohorts of high-risk patients, with similar characteristics, were assessed with a propensity score matching model. The treatment group (HG) (n=225) received the HAR. A historical cohort, exposed to a conventional priming with 1350 mL of crystalloid conformed the control group (CG) (n=210). Results: Exposure to any transfusion was lower in treated (66,75% vs 6,88%, p<0.01). Prolonged mechanical ventilation (>10h) (26.51% vs 12.62%; p<0.01) and extended ICU stay (>2d) (47.47% vs 31.19%; p<0.01) were fewer for treated. HAR did not increase early morbidity and mortality. Related savings varied from 581 to 2741.94 $/patient, depending on if direct or global expenses were considered. Discussion: By reducing the gaseous and crystalloid emboli during CPB initiation, HAR seem to have a beneficial impact in recovery and reduces the overall transfusion until discharge, leading to significant cost savings per process. Due to the preliminary and retrospective nature of the research and limitations, our findings should be validated by future prospective and randomized studies.

Hematic Antegrade Repriming Reduces Emboli on Cardiopulmonary Bypass: A Randomized Controlled Trial

“…Additionally, patients in the treatment group received HAR, according to the standard protocol "in 6 steps." 30 After connecting the arterial line to the patient, the crystalloid content was retrogradely collected, and the venous line content was anterogradely drained to the reservoir. Then, the excess of the crystalloid solution was anterogradely discarded into a collector bag through a recirculation line of the oxygenator.…”

“…*CPB is initiated with VAVD activation once the venous return is obtained. Adapted from the study Blanco-Morillo et al 30 and volume (ml) of GME detected by both probes. The filtration rates were calculated considering the reduction rate from probe 1 to probe 2, regarding to number and volume of GME (Figure 3).…”

“…All circuits were initially primed with 1000 ml of isofundin (B.Braun, Melsungen, Germany), exceeding the minimum operating volume of the reservoir and following the instructions for use described for every oxygenator. Additionally, patients in the treatment group received HAR, according to the standard protocol “in 6 steps.” 30 After connecting the arterial line to the patient, the crystalloid content was retrogradely collected, and the venous line content was anterogradely drained to the reservoir. Then, the excess of the crystalloid solution was anterogradely discarded into a collector bag through a recirculation line of the oxygenator.…”

“…Hematic antegrade repriming (HAR) is a multidisciplinary approach to decrease the hemodilution and impact of cardiopulmonary bypass (CPB), in a standardized manner, to enhance the replicability of the results and avoid the heterogeneity in practice. 1 Despite being inspired by the retrograde autologous priming (RAP) technique, which was initially described by Panico and Neptune 2 and modified by numerous authors, [3][4][5][6] it has been improved with some features to reduce the hemodilutional impact of CPB initiation to a constant amount of 300 ml. Thus, HAR combines some benefits of RAP 2 and venous antegrade priming (VAP) 7 with the advantages of using an open minimized circuit (similar to a MiECC Class IV), 8 vacuum-assisted venous drainage (VAVD), and CPB initiation with an empty venous line.…”

“…*CPB is initiated with VAVD activation once the venous return is obtained. Adapted from the study Blanco-Morillo et al30…”