Are bloodless cardiac surgery programs a fallacy? For the most part, the simple answer is yes they are; unless of course, your cardiac surgery program exists only on the healthiest patients, with active lifestyles, few if any co-morbidities, and not on Clopidogrel and Aspirin. Of course, those cardiac surgery programs are also a fantasy. “With rare exceptions,” Bloodless surgery programs do exist, e.g. Jehovah Witness programs, though truly bloodless surgery programs in the general population are rare.

Allogeneic blood transfusions are a necessary staple of any diverse cardiac surgery program. Nevertheless, the scientific literature is replete with irrefutable data showing that allogeneic transfusions, although at times an absolute necessity, are in fact detrimental to short, intermediate, and long term outcomes, increased infection rates, prolonged ventilator times, disease transmission, allergic reactions, cross match errors, lung injury, increased mortality ₁ , ₂ , ₃ , ₄ , ₅ , ₆ , ₇ , ₈ and are very expensive (Tables 1 and 2). It is estimated that a single unit of packed red blood cells (PRBC's), with an acquisition cost of two hundred U.S. dollars ($200.00) has an actual cost of between one thousand six hundred ($1,600.00) and two thousand four hundred dollars ($2,400.00) to transfuse it to the patient ₉ . This actual cost includes all of the direct and variable personnel costs (Figures 1 and 2) along with the increased costs to any one patient's hospital stay as a result of a transfusion-associated morbidity (Figure 3). The acquisition cost for a unit of aphaeresed platelets is above five hundred U.S. dollars ($500.00 Table 2). Based on the formula used for PRBC's the actual cost of platelets is also incredibly higher. In addition, platelets have also been associated with serious adverse events in cardiac surgery ₁₀ .

Blood banks and collection centers are also feeling the pinch. With Nucleic Acid Amplification (NAT) testing, irradiation, and other tests and treatments to make the available blood supply safer, an already strained system is becoming more expensive coupled with the fact that the allogeneic blood supply operates on a margin of only about ten percent of supply versus demand (Source – America's Blood Centers). The blood supply is safer than ever before, however emerging pathogens are the new concern. West Nile Virus was recently added to blood testing, Chagas disease has been reported to have been transmitted in the US through transfusion and there is no current test available for T.cruzi.

Today, cardiac surgery utilizes approximately twenty to twenty-five percent of the national blood supply and depending on practice, between forty and seventy percent of cardiac patients receive transfusion during their hospital stay ₁₁ . Based on these facts therefore, the national average for blood transfusions in all cardiac patients, not risk stratified, is 7.6 of any blood component per patient.

Following a review of our practice of about 500 cases per year, as well as, a review of several other similar programs, we identified several areas where tools and techniques employed were the greatest contributors to blood transfusion requirements. What we discovered was that the bypass circuit was one area where we could make the greatest impact. However, we discovered that this alone, would only take us so far. What we really needed was a team approach.

We changed our entire perfusion circuit ₁₂ , added full biocompatibility, vacuum assisted venous return, reduced our circuit prime with our own innovative design, matched oxygenator size to patient size, instituted aggressive hemofiltration, became aware and corrected areas of iatrogenic blood loss in the operating room, added full dose Aprotinin ₁₃ , incorporated platelet quality analysis, and elicited the involvement of the entire cardiac surgical team. Today, our blood utilization is approximately two units of any blood product, averaged over all cardiac patients, e.g. CABG/Valve combinations, Bental procedures, triple valve, and in our primary CABG population (usually on Clopidogrel) to less than 1 unit average during the patients hospital stay.

In today's economy, hospitals cannot ignore the realities of decreasing reimbursement and increasing costs. Reducing blood transfusions is a way to improve patient outcomes and improve the Cardiac Hospital's financial health. By implementing a program similar to ours, a cardiac program performing three hundred cases per year and reducing its average per patient blood use by only one unit, would realize a savings of between four hundred eighty thousand ($480,000.00) to as much as seven hundred twenty thousand dollars ($720,000.00) per year (Table 3). For those programs able to reduce their blood usage by one or more units, the savings can be a lifesaver, both for the patients and for the programs.

Figure 1

Table 1

Figure 2

Table 2

Figure 3

Table 3

Figure 4

Figure 1: (Cantor et al, J Oncol, 1998 16(7)2364-70)

Figure 5

Figure 2: (Cremieux et al, J Clin Oncol 2000 18(14) 2755-2761)

Figure 6

Figure 3

Correspondence to

Gary P. Jones, M.D., FACS: Managing member of Louisiana Cardio-Vascular and Thoracic Institute Gjones@LACVT.COM Joseph Basha, Senior Clinical Perfusionist JBasha@LACVT.COM Louisiana CVT Institute 3311 Prescott Road Alexandria, LA 71301. Telephone: 318-442-0106