Malcolm John Robert Dalrymple-Hay

Introduction: 10% of blood issued by the National Blood Service (220 000) is utilised in cardiac procedures. Transfusion reactions, infection risk and cost should stimulate us to decrease this transfusion rate. We tested the efficacy of autotransfusion of washed postoperative mediastinal fluid in a prospective randomized trial.

Objectives: The National Blood Service issues 2.2 million units of blood per year, 10% of these (220 000) are utilized in cardiac procedures. Transfusion reactions, infection risk and cost should stimulate us to decrease this transfusion rate. We test the efficacy of autotransfusion following surgery in a prospective randomized trial. Methods: One hundred and twelve patients undergoing CABG, valve or CABG+valve procedures were randomized into two groups. Group A received washed postoperative drainage fluid and group C were controls. The indication for transfusion was a postoperative haemoglobin (Hb) Results: Twenty-eight patients in group A and 46 in group C required homologous transfusion (P = 0.0008). Group A patients required 298±49 ml of banked blood per patient, group C 508 ± 49 ml (P = 0.003). There was no difference in total blood required (volume autotransfused + volume banked blood transfused) between the groups (group A 404 ± 50 ml, group C 508 ± 50 ml) or in mean total mediastinal fluid drainage (group A 652 ± 51 ml, group C 686 ± 50ml). The mean Hb concentration was significantly higher in group A on day 1 (11.2 g±dl ± 51 vs10.6 g±dl ± 13 (P < 0.002)). No morbidity was associated with autotransfusion. Conclusion: Autotransfusion can decrease the amount of homologous blood transfused following cardiac surgery. This represents a benefit to the patient and a decrease in cost to the health service.

There has been a gradual increase in the number of elderly patients referred for cardiac surgery. These patients present a difficult challenge, they are usually symptomatic yet at high risk for intervention. The aim of this study is to review our experience with cardiac surgery in patients aged 80 years or older. Between January 1981 and October 1997, 242 patients; 135 female, 107 male, mean age 82.8 years (range 80-95) underwent surgery on cardiopulmonary bypass in our unit. Surgery was performed on 14 as an emergency and 136 on an urgent (patient restricted to a hospital bed due to symptoms) basis. Pre-operatively 182 (75.2%) were in NYHA functional class 3 or 4. Early mortality was 14 (5.7%). A mitral valve procedure and emergency surgery were significantly associated (P < 0.05) with an increased risk of operative mortality. Median ITU and in-hospital stay was 1 day (range 0-33) and 10 (range 6-49) days, respectively. Ninety-three percent of patients were living independently at home 2 months post-operatively. Survival (+/-SEM) is 98% complete (totals 557 patient years) and including early mortality at 1 and 5 years was 85.5+/-2.4% (n = 154), and 67.7+/-4.3% (n = 33). Survival for patients undergoing isolated aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) at 5 years was 64.8+/-7.8% and 79.7+/-7.4%, respectively. Survival was significantly worse in patients undergoing a mitral procedure. Using Cox's proportional hazards model only type of operation (mitral surgery) was significantly associated with worse survival. Cardiac surgery can be performed in a selected elderly population with a low operative mortality. Post-operatively elderly patients attain an excellent quality of life and survival. Emergency and mitral surgery in this group of patients is less rewarding.