Bloodless Heart Surgery

Promohealth bloodless surgery programBloodless heart surgery is transfusion free cardiac surgery, where the patient’s wishes are respected based not only on religious beliefs but also with the intention of trying to avoid the potential risks associated with blood transfusions, such as infections, complications and mortality.
Any type of heart surgery can be performed without blood, including complex operations, and depends solely upon the patient’s state of health, which is evaluated prior to surgery in order to determine if surgery can take place. If necessary, treatment to address the patient’s health is carried out in order to be able to carry out this type of surgery.
Under the tutorship and direction of Dr. Ruyra, an expert Cardiac Surgeon, our bloodless cardiac surgery team has become an international benchmark, treating patients from all over the world. Mortality under Dr. Ruyra’s expert hands in bloodless cardiac surgery is 1.5% when the expected mortality was 11.8% (Euroscore log), proving that that we deliver first class results of the highest quality.

Why Bloodless Medicine and Surgery?

Bloodless medicine and surgery is possible, even in specialties such as cardiac surgery, which are potentially very bloody. Issues to consider regarding blood transfusions:

  • Blood is a scarce commodity. There is more demand than supply.
  • Blood transfusions are a therapeutic procedure that is not exempt from complications.
  • The use of hemoderivatives has a high cost.
  • Additionally there are many countries where the blood used is not safe.

The transfusion must always be viewed with caution because it involves a number of general risks:

  • Infection. Although blood is very safe in developed countries, there is always danger of infection.
  • Lung problems.
  • Idiosyncratic reactions.
  • May cause immunomodulation. It produces a metabolic and immunological overexertion.
  • It can reduce immunocompetence. Reducing the body’s immune system i.e. the defense capacity of our body which in turn can:
    • Activate viral infection
    • Increase postoperative infections
    • Cause cancer recurrences

More specifically, the risks of blood transfusion are:

Risk Blood Transfusions

It is important to realize that the viral and parasitic infectious risks of blood transfusion are dramatically increased in third world countries or in areas where modern blood banking practices are not available (

A study by Jama (The Journal of the American Medical Association) about the habitual practice of transfusions in a large number of Intensive Care Units (ICUs) in USA and Europe showed that transfusions increased infections, patient stays in hospital and mortality. In 66% of cases the transfusion had no clinical or physiological indication.

Bloodless Surgery within the specialty of Cardiac Surgery

15% -20% of all hospital transfusions in any one country are for cardiac surgery. This is a significant number when you consider that heart surgery represents only about 2% of all surgeries that are carried out in any one country.

15% -20% of all hospital transfusions in any one country are for cardiac surgery. This is a significant number when you consider that heart surgery represents only about 2% of all surgeries

There is sufficient evidence and studies which show that the results are better in patients who have undergone heart surgery if they have not needed hemoderivatives.

The latest guidelines of the Associations of Thoracic Surgeons and Specialist Anesthetists in Cardiac Surgery make it clear that we must try not to transfuse patients who undergo heart surgery. It has been recognized that a patient who has received a transfusion has a shorter life span, and even long-term survival is directly related to the number of concentrates the patient receives. In every case, this patient has greater morbidity: renal failure, prolonged intubation, major infections, cardiac morbidity, low cardiac output, neurological morbidity.

There is astounding and universal evidence to show that a patient who receives a transfusion in cardiac surgery is more likely to have higher mortality in the short, medium and long term than someone who does not undergo a transfusion, and there is even a study that claims it can affect the patient’s life in the long term.

Is it possible to have Bloodless Cardiac Surgery?

Yes, it is possible. However, this does not mean it is easy. We must take into account four main aspects:

  1. Mentality: one must be clear that a transfusion is not a good option, and that is why it should be avoided.
  2. The Team: the whole team must be clear that everything must be done in order to ensure the patient does not receive a transfusion.
  3. Program: there should be a specific blood conservation program.
  4. Know-how: you have to know how to do it.

In cardiac surgery, in most cases the patient has to be connected to a heart-lung machine that carries out the oxygenation and will function as a heart pump (cardiopulmonary bypass or CPB). Working with CPB will allow the heart to be stopped, and the temperature to be raised and lowered etc. This determines (and this is where cardiac surgery is different from other types of surgery) that all the blood we pump passes again through a pump that is then returned to the patient, and again and again, thousands of times until the operation is complete. This causes a number of alterations in the homeostasis that promote bleeding: haemodilution, platelet disorder, a change in clotting factors, consumptive coagulopathy, triggered fibrinolysis and a global inflammatory response.

How to implement a Bloodless Cardiac Surgery Program

  1. Integral: it addresses all patient care needs.
  2. Transverse: the cardiac surgery patient, from entering the hospital until he comes out, goes through many phases and many doctors, and they all have to share a continuity in terms of the way of thinking.
  3. Multidisciplinary: because it involves many different specialties.
  4. Multimodal: we must act at different times within the process and with different techniques.
  5. Individualized: as an example, a lady measuring 5ft with preoperative haemoglobin of 11 is not the same as a 6ft man with preoperative haemoglobin of 11. One will be operated on easily without blood transfusion whilst the other will not.

Bloodless cardiac surgery-3

Actions to minimize or prevent blood loss or transfusion

There are between 50 to 60 different options available. The know-how allows you to mix and adapt them to each patient, since each case is different.

Preoperative Measures

  1. Identify the patient’s risk of bleeding. There are some risk standards available such as the “Toronto Risk model” that values the following as the most important: age, body surface area and preoperative hemoglobin. For example, with a small body surface area we have a small blood volume, which means that when a small amount of blood is lost, it will have a very large impact on the overall blood volume.
  2. Optimizing the preoperative hemoglobin level. This can be achieved if there is enough preoperative preparation time. In cases of emergency surgery, this is not possible.
  3. Discontinuing anticoagulant and antiplatelet treatments. It is good to stop taking them a few days before the operation, if possible, so that there is less antiplatelet activity (which increases the chance of bleeding).
  4. Complete laboratory studies carried out for coagulation and platelet function.
  5. Assess the possibility of an autonomous pre-donation. That is, take the patient’s blood a few months before surgery, store it and then it can be used at the time of surgery.

Intra-operative measures

The first 3 are the most important.

  1. Surgical strategy. We must be clear about how we will make the approach, minimize downtime and extracorporeal circulation time, use normothermia … all with the objective of maximizing effectiveness and blood conservation.
  2. An extremely diligent and careful technique: very little margin for error. The patient who can be transfused can handle a greater margin of error, but there are groups such as those who refuse transfusion, where the margin for error is minimal.
  3. Monitoring the outcome. There are means to see if the surgery that we have performed has been carried out correctly (Intraoperative Transesophageal ECO, graft flow measurement, the monitoring of cerebral perfusion), all of which are standard in our “Smart Cardiac Surgery Program”.
  4. Normovolemic hemodilution (if Hb <14). Blood can be taken when the patient has good haemoglobin (preoperatively) and that space can be filled with saline solution, crystalloids or colloids, so that what is lost during surgery has less hemoglobin. Then, when surgery is over, the patient can receive his own blood with all its properties and the target haematocrite that we are interested in.
  5. The use of biocompatible extracorporeal circulation circuits. This causes less damage to the blood.
  6. Avoid or reduce as much as possible hemodilution.
    1. Adaptation of the extracorporeal circulation circuit to the patient. If a patient has to be connected to a heart-lung pump that has a hose, a reservoir, etc., this space must be filled with fluid, and this is what dilutes the patient’s blood. But it must be diluted as little as possible. How can this be done? Until recently, the same circuit was used for a 100 kg patient, a woman of 35 kg or a child of 18 kg. Now, however, the circuits are adapted to be either smaller or bigger, depending on the patient’s weight.
    2. Avoid liquid infusion or anesthetic induction.
    3. Set the “priming” or initiation of the extracorporeal circulation circuit.
    4. RAP (Retrograde Autologous Priming). Using the patient’s own blood to fill the space required for the pump and tubing, in a retrograde manner.
    5. Miniplegia. Using the patient’s blood with potassium.
    6. Recovery of excess blood in the circuit.
    7. Encourage extracorporeal circulation drainage.
  7. Heparin/Protamine control. Identify HepNa resistance.
  8. Avoid unnecessary aspiration/suction.
  9. The use of antifibrinolytic drugs.
  10. Blood or cell recuperators. Depending on each patient, the following can be used: the Cell-saver (works well to retrieve blood); the Hemobag (the most interesting recuperator for bloodless surgery because it produces blood high in hematocrit but with high osmotic pressure, which conserves proteins and anticoagulation properties); or Modified Ultrafiltration.
  11. Topical hemostatics: compression agents or sealant agents.
  12. Waiting in post-closure operating room. At least 1 hour. Coagulation tests.

Autologous blood reinfusion bag

Postoperative Measures

  1. Explain to the ICU professionals if there are open pleurae or not, if there are points of potential bleeding or not, if hemostasis has been adequate or not, so that, with these important facts in mind, the patient can be better monitored.
  2. Active surveillance. Diligent and very demanding criteria for reintervention due to bleeding, because if a lot of time is spent waiting, the opportunity to resolve the bleeding can be missed.
  3. Consensus on transfusion criteria. No transfusion to be carried out outside the strict protocolized criteria.

Bloodless cardiac surgery-2

Results of Operations in Dr. Ruyra’s Bloodless Cardiac Surgery Program

65 patients between 2007 and 2012, mostly Jehovah’s Witnesses.

They were high-risk patients (type A dissections, Ross operation with aorta, multiple reinterventions, etc.). Expected mortality (Euroscore log.) was 11.8% . However, real obtained mortality was only 1.5% (in fact 1 patient died of neurological and not cardiac problems). No patient had bleeding problems or derivatives. And of course, no patient was transfused.

Complications: levels comparable to standard surgeries. Hospital stay similar to that of other patients (8.2 days ± 2.5 days).


  • The use of blood products increases patient morbidity & mortality after cardiac surgery.
  • Bloodless cardiac surgery can be performed safely and effectively, even in high-risk patients.
  • It is necessary to raise awareness among professionals, and introduce blood conservation programs in surgery, particularly in cardiac surgery, where blood loss is very important.
Bloodless Surgery
Phone: +34 93 220 28 09

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