Bloodless cardiac surgery: a strategy for few or the future standard of care?

P roviding access to medical therapy for patients who are unable to receive blood transfusion on the basis of religious or other principles is an important clinical challenge. In preparation for meeting the needs of these patients, practitioners should assess whether alternate approaches to medical and surgical management allowing for bloodless care are feasible. On the basis of research with these patients, there is now evidence that blood-sparing strategies can generate outcomes superior to those resulting from the current state-of-the-art management applied to the wider patient population. The challenges of bloodless surgery are particularly relevant to the field of cardiovascular surgery, where the incidence of blood transfusion remains high. During the 2014 reporting interval, the transfusion rate was 44.5% among participants in the Society of Thoracic Surgeons (STS) National Database for isolated coronary artery bypass grafting (CABG) procedures. In the 1970s, the door to bloodless cardiovascular surgical care was initially opened after a large series of successful bloodless cardiovascular surgery cases were reported. Since that time, advances have been made in the perioperative management of these patients, including improved bypass circuits, acute normovolemic hemodilution, off-pump CABG, minimally invasive techniques, and enhanced hemostatic techniques for the surgical field. Although these advances have greatly increased our capability to conduct bloodless cardiovascular surgery procedures ranging from CABG to cardiac transplantation safely, bloodless cardiovascular surgery remains an option limited to select patients in most centers. One of the most important contributions to patient blood management is the development of effective strategies for managing preoperative anemia, which is a key predictor of blood transfusion in cardiovascular surgery, as well as in other surgical settings. Preoperative anemia that is amenable to correction with iron and, sometimes, with erythroid-stimulating agent (ESA) therapy, is commonly encountered in preoperative cardiovascular surgery patients, especially those who are female or elderly. However, ESAs are used sparingly in the cardiovascular surgery setting because of concerns about treatmentrelated adverse events, most notably thrombosis, which has been observed primarily in renal and cancer patients on long-term therapy. Furthermore, concerns regarding cost and delay to surgery remain issues that impede the wider application of patient blood management schemes in preoperative care. Recently, the blood-sparing benefit of ESA therapy was reported in a series of cardiac surgery patients who received a single ESA dose 2 days before surgery and showed no increase in adverse events. In this issue of TRANSFUSION, Guinn and colleagues address the cost of providing bloodless cardiovascular surgery, which until now has been an unevaluated question in this specific patient population. The study employs cost data from multiple expense categories derived from an institutional accounting system, and the authors analyze in a case-matched study the cost of bloodless cardiovascular surgery compared to that of standard care. The true cost of medical interventions is often difficult to determine, given the opaqueness of medical economics in many health care systems. Although a detailed methodology of cost determination is not described, this report provides the analysis of inpatient treatment cost from the day of surgery until discharge. Any analytical weakness with respect to cost-price consideration should have similarly affected both groups. Though one may disagree with the method used to determine true cost, the comparative cost estimates described in the study for the period assessed are sound. The data presented in this report showed that the overall cost of inpatient bloodless cardiovascular surgery care matched that of controls for the period studied. As expected, supply and diagnostic costs (including blood and laboratory expenses) were subcategories with clear cost reduction. One common concern in providing bloodless surgery is the length of hospital stay and the operating room time required for the bloodless support of patients. This study showed that the length of hospital stay from the day of surgery onward was not increased for bloodless surgery patients when compared with that for controls. Rather, an interesting finding from this study was that the postoperative length of hospital stay was shorter for bloodless surgery patients than for controls. Although the initial length of hospital stay was not factored into the analysis, it was prolonged in bloodless surgery patients compared to controls. This observation may be attributed to the facility’s status as a tertiary referral center and/or less developed outpatient services in early phases of the decades-long study interval. In recent years, there has been a growing application of outpatient preoperative management designed to ensure that all patients are adequately prepared for surgery. A very important finding among patients in this study was the similar amount of time spent in the doi:10.1111/trf.13365