title: Is elimination of cardiotomy suction preferable in aortic valve replacement? Assessment of perioperative coagulation, fibrinolysis and inflammation.
abstract: OBJECTIVE
  Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes.
  
  
  METHODS
  In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n = 20) or CATS (Cell-Saver group, n = 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery.
  
  
  RESULTS
  Perioperative values for coagulofibrinolysis markers, such as thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-Cell-Saver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P < 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P = 0.004). There were no significant differences in the other clinical outcomes between the two groups.
  
  
  CONCLUSIONS
  In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. A CATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.
authors.affiliation: Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Akimasa
authors.initials: A
authors.lastname: Morisaki
authors.forename: Atsushi
authors.initials: A
authors.lastname: Nakahira
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Sasaki
authors.forename: Hidekazu
authors.initials: H
authors.lastname: Hirai
authors.forename: Yuko
authors.initials: Y
authors.lastname: Okada
authors.forename: Shigefumi
authors.initials: S
authors.lastname: Suehiro
authors.forename: Toshihiko
authors.initials: T
authors.lastname: Shibata
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage; D015415:Biomarkers / Q000097:blood; D001777:Blood Coagulation / Q000187:drug effects; D001804:Blood Transfusion, Autologous; D002315:Cardiopulmonary Bypass; D016009:Chi-Square Distribution; D017707:Erythrocyte Transfusion; D005260:Female; D005342:Fibrinolysis / Q000187:drug effects; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007249:Inflammation / Q000097:blood / Q000209:etiology / Q000517:prevention & control*; D018836:Inflammation Mediators / Q000097:blood; D008297:Male; D057725:Operative Blood Salvage / Q000009:adverse effects / Q000379:methods*; D011446:Prospective Studies; D013396:Suction; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D015415:Biomarkers; D018836:Inflammation Mediators
keywords: Blood coagulation; Extracorporeal circulation; Fibrinolysis; Valve diseases