Point-of-care coagulation management during surgery with minimal invasive extracorporeal circulation (Free)

Abstract

Contemporary advances in cardiac surgery have markedly improved clinical outcomes. However, cardiac surgery is still hampered by considerable morbidity and subsequent mortality, especially in complex and high-risk procedures, as evidenced in the largest cardiac surgery registry (1). A strong contributing factor is postoperative coagulation derangement mainly due to the use of cardiopulmonary bypass (CPB). The resultant acute postoperative bleeding is a life-threatening major resource-consuming complication that impairs outcome (2).

The development of cardiac anesthesia contributed major progress to postoperative hemostasis via the integration of point-of-care (POC) monitoring of coagulation. A contemporary POC laboratory in the operating room (OR) includes thromboelastography (TEG, Haemonetics) or rotational thromboelastometry (ROTEM, TEM Innovations), aggregometry, and individualized heparin management (HMS, Medtronic) for precise titration of heparin and protamine (Table 1). The implementation of POC monitoring during cardiac surgery has significantly expanded our knowledge on the pathophysiology of coagulation derangement intraoperatively and led to advanced targeted treatment.

The development of POC coagulation management coincided with an evolution in perfusion science which was the establishment of minimal invasive extracorporeal circulation (MiECC) in clinical practice. MiECC represents a cutting-edge perfusion technology that integrates all contemporary advancements in perfusion in a closed circuit with biologically inert blood contact surfaces; this offers enhanced biocompatibility and provides optimal perfusion, which ultimately better preserves end-organ function (3). Our department is a leading institution in the field of MiECC research and technology that is routinely applied to all types of cardiac surgical procedures (4). We implement MiECC use in the context of a multidisciplinary perioperative strategy for attaining “more physiologic” cardiac surgery, as presented earlier in this focused issue (5).