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J Thorac Cardiovasc Surg 2005;129:1200
© 2005 The American Association for Thoracic Surgery
Letters to the Editor |
Department of Cardiovascular Surgery, Children’s National Medical Center, Washington, DC 20010
To the Editor:
We read with interest the report by Ootaki and associates,1 as well as the correspondence by Shuhaiber2 in reference to the article by Habib and colleagues.3 Ootaki and coworkers1 applied a transfusion protocol in which blood was not transfused during cardiopulmonary bypass unless hematocrit was less than 15%. They found that patients with a hematocrit of less than 20% had a higher lactate level than patients with a higher hematocrit but imply that this has no functional significance.
In their critique of the article by Habib and associates,3 which emphasized the value of the lowest hematocrit as a predictor of outcome, Shuhaiber2 implied that a hematocrit of 20% is a useful transfusion trigger. They also called for a prospective randomized study of hematocrit, as did Habib’s group.
At the 2002 meeting of the American Association for Thoracic Surgery, we presented the results of a prospective randomized trial of 2 hemodilution strategies.4 This study was shut down by the Data and Safety Monitoring Board of the National Institutes of Health because of a strongly positive outcome. Infants who had a mean hematocrit of 27.8% ± 3.2% (n = 73) had significantly better motor skills at 1 year of age relative to patients whose lowest hematocrit on bypass was 21.5% ± 2.9% (n = 74). A significantly greater percentage of patients at 1 year of age were classified as developmentally delayed with respect to motor skills relative to patients perfused at a higher hematocrit. The lactate level 1 hour after bypass was significantly lower with the higher hematocrit.
The findings of our prospective randomized study are consistent with several previous reports derived from our laboratory work in this area.5–7 Studies using near-infrared spectroscopy suggest that acute hemodilution during cardiopulmonary bypass results in cerebral hypoxia. It is important to remember, before discarding the significance of our clinical trial as being irrelevant to adults because it was performed in infants, that the mature brain is significantly more sensitive to hypoxic injury than the neonatal and infant brain. Nevertheless, we strongly endorse the call for a prospective randomized trial of hematocrit in adults undergoing cardiopulmonary bypass, including sensitive end points such as assessment for cognitive dysfunction. In the meantime, we strongly recommend that a hematocrit of at least 25% and preferably closer to 30% should be used during cardiopulmonary bypass.
References
This article has been cited by other articles:
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  F. Pappalardo, C. Corno, A. Franco, G. Giardina, A.M. Scandroglio, G. Landoni, G. Crescenzi, and A. Zangrillo Reduction of hemodilution in small adults undergoing open heart surgery: a prospective, randomized trial Perfusion, September 1, 2007; 22(5): 317 - 322. [Abstract] [PDF]
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 J. Shuhaiber Long-term Mortality Associated With Aprotinin Following Coronary Artery Bypass Graft Surgery JAMA, June 13, 2007; 297(22): 2476 - 2476. [Full Text] [PDF]
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