**Hemotherapy in Cardiac Surgery**

### Robert Wagner

*Centre for Cardiovascular and Transplant Surgery, St Anne's University Hospital, Masaryk University, Brno Czech Republic*

#### **1. Introduction**

166 Perioperative Considerations in Cardiac Surgery

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Demands for allogeneic blood transfusion in cardiac surgery were still high two decades ago. Today there is a gradual decline in transfusion requirements owing to recent advances in cardiac surgery and related specialties that have together developed techniques for perioperative blood salvage and its autotransfusion; this trend continues to progress towards bloodless surgery. Its milestones have included a refinement of surgical methods, a better understanding of bleeding pathology related to extracorporeal circulation and an introduction of coagulation monitoring during surgery, using point-of-care testing [1,2,3,4,5]. A significant advancement in extracorporeal circulation came with the development of less aggressive, more biocompatible and miniature-circuit systems [6, 7]. As a result, allogeneic blood transfusion is currently not needed in over 50% of all surgical procedures and in almost 100 % of coronary heart operations [8,9]. However, over 40 % of patients undergoing cardiac surgery still require allogeneic blood transfusion; of them, 5-7 % show an excessive blood loss (more than a normal circulating blood volume), 10-15 % have a large blood loss (more than 2000 ml) and about 15-20 % have a moderate blood loss (1000 ml to 2000 ml) during the day of surgery up to 7 am next day. The average transfusion requirement ranges between 2 and 4 units of packed red blood cells (PRBC) per adult patient, depending on the centre. Cardiac surgery centers commonly utilize 10 to 15 % of the RBCs production of the regional blood bank centers [10].

In the last two decades, the efforts to develop techniques for refinements of surgical methods and peri-operative blood salvage have intensified because of an increase in the number of reoperations and surgery on elderly, polymorbid patients with preoperative anemia. These are the major components of a multi-modality strategy that involves the preoperative preparation of a patient, surgical procedures, drug administration and homeostatic maintenance (Table 1).

#### **2. Autotransfusion**

Autotransfusion in cardiac surgery can be divided into three steps according to collection time and the method used, namely, pre-operative autologous blood donation, intraoperative blood collection and post-operative blood salvage.

Table 1. Policy for limitation of blood bank transfusion in cardiac surgery


**2. Patient selection**

Patients are nominated for pacemaker (PPM) and implantable cardiac defibrillator (ICD) implantation according to the patient's history, symptoms and signs, physical examinations and other documents, cardiac imaging (echocardiography) in case of bradycardia/tachycardia, and based on the 2021 European Society of Cardiology (ESC) guidelines on cardiac pacing and cardiac resynchronization therapy, which was developed by the Task Force on cardiac pacing and cardiac resynchronization therapy [1].

A majority of all pacemaker implantations are indicated to patients above 60 years old. After admitting the patient and obtaining informed consent, the necessary blood tests, chest X-ray, and electrocardiography are taken, and then the patient is prepared for the procedure. The patient is transferred to the electrophysiology laboratory, where it is essential to have properly functioning equipment. In addition, standard air conditioning is crucial in controlling air infections. In the era of the Covid-19 pandemic, we need to consider health protocols and guidelines for the personal protection of staff and patients. If there is no emergency condition, pacemaker and ICD implantation should be delayed; otherwise, we must follow all the instructions and protocols related to the prevention of the disease.