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Drug, Devices, Technologies, and Techniques for Blood Management in Minimally Invasive and Conventional Cardiothoracic Surgery: A Consensus Statement From the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011

Menkis, Alan H. MD*; Martin, Janet PharmD, MSc (HTA); Cheng, Davy C.H. MD; Fitzgerald, David C. CCP; Freedman, John J. MD§; Gao, Changqing MD; Koster, Andreas MD, PhD; Mackenzie, G. Scott MD#; Murphy, Gavin J. MD**; Spiess, Bruce MD††; Ad, Niv MD‡‡

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: July/August 2012 - Volume 7 - Issue 4 - p 229–241
doi: 10.1097/IMI.0b013e3182747699
Consensus Statement

Objective The objectives of this consensus conference were to evaluate the evidence for the efficacy and safety of perioperative drugs, technologies, and techniques in reducing allogeneic blood transfusion for adults undergoing cardiac surgery and to develop evidence-based recommendations for comprehensive perioperative blood management in cardiac surgery, with emphasis on minimally invasive cardiac surgery.

Methods The consensus panel short-listed the potential topics for review from a comprehensive list of potential drugs, devices, technologies, and techniques. The process of short-listing was based on the need to prioritize and focus on the areas of highest importance to surgeons, anesthesiologists, perfusionists, hematologists, and allied health care involved in the management of patients who undergo cardiac surgery whether through the conventional or minimally invasive approach. MEDLINE, Cochrane Library, and Embase databases were searched from their date of inception to May 2011, and supplemental hand searches were also performed. Detailed methodology and search strategies are outlined in each of the subsequently published systematic reviews. In general, all relevant synonyms for drugs (antifibrinolytic, aprotinin, [Latin Small Letter Open E]-aminocaproic acid, tranexamic acid [TA], desmopressin, anticoagulants, heparin, antiplatelets, anti-Xa agents, adenosine diphosphate inhibitors, acetylsalicylic acid [ASA], factor VIIa [FVIIa]), technologies (cell salvage, miniaturized cardiopulmonary bypass (CPB) circuits, biocompatible circuits, ultrafiltration), and techniques (transfusion thresholds, minimally invasive cardiac or aortic surgery) were searched and combined with terms for blood, red blood cells, fresh-frozen plasma, platelets, transfusion, and allogeneic exposure. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of each recommendation.

Results and Recommendations Database search identified more than 6900 articles, with 4423 full-text randomized controlled trials assessed for eligibility, and the final 125 systematic reviews and meta-analyses were used in the consensus conference. The results of the consensus conference, including the evidence-based statements and the recommendations, are outlined in the text, with references given for the relevant evidence that formed the basis for the statements and recommendations.

From the *WRHA Cardiac Sciences Program, Department of Surgery, University of Manitoba, Winnipeg, MB Canada; †Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR), Department of Anesthesia and Perioperative Medicine, Western University, London, ON Canada; ‡Inova Heart and Vascular Institute, Falls Church, VA USA; §Division of Hematology, Department of Medicine, St. Michael Hospital, Toronto, ON Canada; ∥Department of Cardiovascular Surgery, Minimally Invasive and Robotic Cardiac Surgery Center, PLA General Hospital, Beijing, China; ¶Heart and Diabetes Center NRW, Bad Oeynhausen, Germany, Ruhr-University Bochum, Germany; #Cardiac Anesthesia, WRHA/SBGH Cardiac Sciences Program, Winnipeg, MB Canada; **Glenfield Hospital, University of Leicester, Leicester, UK; ††Department of Anesthesiology, Virginia Commonwealth University/Medical College of Virginia, Richmond VA USA; and ‡‡Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA USA.

Accepted for publication August 29, 2012.

Supported by the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), which has received unrestricted educational grants from industries that produce surgical technologies and from the Department of Anesthesia & Perioperative Medicine, Western University, London, ON Canada.

Disclosure: John J. Freedman, MD, is a speaker and receives consultant fees for Ethicon Biosurgery, Markham, ON Canada; Gavin J. Murphy is a consultant to Novo Nordisk, Bagsvaerd, Denmark and Ethicon Biosurgery, Somerville, NJ USA; Niv Ad, MD, is a speaker and receives consulting fees for Medtronic, Inc., Minneapolis, MN USA, AtriCure, Inc., West Chester, OH USA, and Estech, Inc., San Ramon, CA USA. Alan H. Menkis, MD, Janet Martin, PharmD, MSc (HTA), Davy C.H. Cheng, MD, David C. Fitzgerald, CCP, Changqing Gao, MD, Andreas Koster, MD, PhD, G. Scott MacKenzie, MD, and Bruce Spiess, MD, declare no conflict of interest.

Address correspondence and reprint requests to Davy C.H. Cheng, MD, FRCPC, Department of Anesthesia and Perioperative Medicine, LHSC-University Hospital, 339 Windermere Rd, London, ON Canada N6A 5A5. E-mail:

Copyright © 2012 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.