We would like to comment on the “Update on Blood Conservation for Cardiac Surgery” published in the February 2012 issue of the Journal of Cardiothoracic and Vascular Anesthesia.1Nalla B.P. Freedman J. Hare G.M.T. et al.Update on blood conservation for cardiac surgery.J Cardiothorac Vasc Anesth. 2012; 26: 117-133Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar While we applaud the extensive and thoughtful work that went into this publication, we would like to raise several issues that we believe are oversights in the section pertaining to topical hemostatic agents. The discussion of fibrin sealants should include EVICEL® (Ethicon, Inc, Somerville, NJ) Fibrin Sealant (Human). EVICEL is a fibrin sealant marketed in the United States, with a general hemostasis indication, and is the only fibrin sealant that is both aprotinin free and tranexemic acid free. One of the 3 pivotal trials for EVICEL to gain a general hemostasis indication was in vascular surgery, which showed safety and efficacy for use at anastomotic sites.2Chalmers R.T. Darling III, R.C. Wingard J.T. et al.Safety and effectiveness of a tranexamic acid-free fibrin sealant during vascular surgical procedures: Results of a randomised multicentre study.Br J Surg. 2010; 97: 1784-1789Crossref PubMed Scopus (42) Google Scholar With regard to flowable gelatin topical hemostatic agents, we believe these should be considered as a class. Only Floseal is mentioned by name although that class includes SURGIFLO (Ethicon, Inc) Hemostatic Matrix, a flowable gelatin. SURGIFLO is a flowable form of SURGIFOAM (Ethicon, Inc) Absorbable Gelatin Sponge. Data from a multicenter prospective, randomized, controlled clinical trial for SURGIFOAM, which included vascular anastomoses, was accepted by the Food and Drug Administration for the purposes of approving SURGIFLO. Because this gelatin product can be constituted as a pad, powder, or flowable, they are, in effect, viewed as the same agent. Notably, the pivotal randomized controlled trial for EVITHROM (Ethicon, Inc) thrombin using SURGIFOAM as a carrier also included cardiovascular patients.3Doria C. Fischer C.P. Wood C.G. et al.Phase 3, randomized, double-blind study of plasma-derived human thrombin versus bovine thrombin in achieving hemostasis in patients undergoing surgery.Curr Med Res Opin. 2008; 24: 785-794Crossref PubMed Scopus (38) Google Scholar Finally, SURGIFLO, which may be used with or without thrombin, is derived from porcine gelatin. Because Floseal's bovine origin is a potential concern, SURGIFLO should be considered as an alternative. In the section on thrombin, mention is made that concerns over the formation of bovine-induced antithrombin antibodies lead to the development of recombinant human thrombin. We would like to point out that the Food and Drug Administration approved EVITHROM thrombin in 2007, the first human-derived thrombin available in the United States. We hope this letter will contribute to the document as an addendum. We thank the multiple authors of this document for their efforts and dedication to promoting the conservation of blood products in cardiovascular surgery and improving the quality of care for all patients. Update on Blood Conservation for Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 1PreviewPATIENTS UNDERGOING CARDIAC SURGERY are at risk of excessive bleeding, leading to increased usage of allogeneic blood and hemostatic blood products. Although this patient population represents a relatively small proportion of surgical patients, cardiac surgery consumes about 20% of the available blood supply in the United States,1 with similar numbers reported worldwide.2,3 The potential for beneficial effects of transfusing blood to maintain tissue oxygen perfusion and prevent organ ischemia may be greatest in patients with cardiovascular disease. Full-Text PDF