title: Redo sternotomy for cardiac reoperations using peripheral heparin-bonded cardiopulmonary bypass circuits without systemic heparinization: technique and results.
abstract: OBJECTIVE
  Cardiac reoperations are challenging and time-consuming and incur a high incidence of perioperative complications because of injuries to cardiac structures, bleeding, and hemodynamic instability. Some centers are using extracorporeal circulation with heparinization at the time of resternotomy, but it leads to prolonged anticoagulation, platelet dysfunction, fibrinolysis, coagulopathy, and morbidity. The authors routinely perform resternotomy in complex surgery with the support of heparinless cardiopulmonary bypass with heparin-bonded circuits (HBCs). The authors describe their technique, indication, and results.
  
  
  METHODS
  The femoral artery or axillary artery and femoral veins are cannulated before sternotomy, and cardiopulmonary bypass is instituted using an HBC without systemic heparinization. Systemic heparin (200-300 U/kg) is administered when all structures are isolated before aortic cross-clamping (activated coagulation time >400 seconds).
  
  
  RESULTS
  Between 1996 and 2008, 336 patients underwent redo sternotomy using the HBC for complex cardiac procedures, with 29 deaths (8.6% deaths within 30 days). Only 5 (1.5%) of 336 patients sustained injury to the right ventricle, aorta, bypass grafts, or ventricular fibrillation during re-entry without hemodynamic deterioration; and underwent uneventful repair and outcomes. There was no online HBC thrombosis.
  
  
  CONCLUSIONS
  This study shows that HBC without systemic heparinization during resternotomy can be used safely in complex redo cardiac surgery. The heart is completely decompressed during the resternotomy, allowing easy dissection, less likely injury to vital structures, and less bleeding without compromising the hemodynamics.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, The Warren Alpert School of Brown University, Rhode Island Hospital, Providence, RI, USA.
authors.forename: Arun K
authors.initials: AK
authors.lastname: Singh
authors.forename: Gary
authors.initials: G
authors.lastname: Stearns
authors.forename: Andrew
authors.initials: A
authors.lastname: Maslow
authors.forename: William C
authors.initials: WC
authors.lastname: Feng
authors.forename: Carl
authors.initials: C
authors.lastname: Schwartz
mesh_terms: D006348:Cardiac Surgical Procedures / Q000295:instrumentation* / Q000379:methods; D002315:Cardiopulmonary Bypass / Q000379:methods*; D005112:Extracorporeal Circulation / Q000379:methods*; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D012086:Reoperation / Q000379:methods*; D024162:Second-Look Surgery / Q000379:methods; D056346:Sternotomy / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D006493:Heparin