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Leviner DB, Ronai T, Abraham D, Eliad H, Schwartz N, Sharoni E. Minimal Learning Curve for Minimally Invasive Aortic Valve Replacement. Thorac Cardiovasc Surg 2025; 73:296-303. [PMID: 38830605 DOI: 10.1055/a-2337-1978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Minimally invasive aortic valve replacement (MiAVR) is an established technique for surgical aortic valve replacement (AVR). Although MiAVR was first described in 1993 and has shown good results compared with full sternotomy AVR (FSAVR) only a minority of patients undergo MiAVR. We recently started using MiAVR via an upper hemisternotomy. We aimed to examine the early results of our initial experience with this technique. METHODS We compared 55 MiAVR patients with a historical cohort of 142 isolated FSAVR patients (December 2016-December 2022). The primary outcome was in-hospital mortality. Secondary outcomes included cardiopulmonary bypass (CPB) and cross-clamp times, blood product intake, in-hospital morbidity, and length of intensive care unit and hospital stay. RESULTS There was no significant difference in preoperative characteristics, including age, laboratory values, and comorbidities. There was no significant difference between the groups regarding in-hospital mortality (FSAVR 3.52 vs. MiAVR 1.82%). There was no significant difference in CPB time (FSAVR 103.5 [interquartile range: 82-119.5] vs. MiAVR 107 min [92.5-120]), aortic cross-clamp time (FSAVR 81 [66-92] vs. MiAVR 90 min [73-99]), and valve size (FSAVR 23 [21-25] vs. MiAVR 23 [21-25]). The incidence of intraoperative blood products transfusion was significantly lower in the MiAVR group (10.91%) compared with the FSAVR group (25.35%, p = 0.03). CONCLUSION Our findings further establish the possibility of reducing invasiveness of AVR without compromising patient safety and clinical outcomes. This is true even in the learning curve period and without requiring any significant change in the operative technique and dedicated equipment.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiothoracic Surgery, Carmel Medical Center Cardiovascular Center, Haifa, Israel
- Technion Israel Institute of Technology, Haifa, Haifa, Israel
| | - Tom Ronai
- Technion Israel Institute of Technology, Haifa, Haifa, Israel
| | - Dana Abraham
- Technion Israel Institute of Technology, Haifa, Haifa, Israel
| | - Hadar Eliad
- Department of Cardiothoracic Surgery, Carmel Medical Center Cardiovascular Center, Haifa, Israel
| | - Naama Schwartz
- Carmel Medical Center, Research Authority, Haifa, Haifa, Israel
| | - Erez Sharoni
- Department of Cardiothoracic Surgery, Carmel Medical Center Cardiovascular Center, Haifa, Israel
- Technion Israel Institute of Technology, Haifa, Haifa, Israel
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Noitz M, Brooks R, Schlömmer C, Tschoellitsch T, Mahečić TT, Baronica R, Maletzky A, Zierer A, Dünser MW, Meier J. Central/mixed venous oxygen saturation and lactate levels might be of limited use as physiologic transfusion triggers in cardiac surgery: Results of a retrospective analysis. Eur J Anaesthesiol 2025; 42:536-542. [PMID: 40017409 DOI: 10.1097/eja.0000000000002149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 12/10/2024] [Indexed: 03/01/2025]
Abstract
BACKGROUND Current guidelines differ in their recommendations regarding the use of physiologic transfusion triggers to guide transfusion practice. Data on the interaction between haemoglobin (Hb) and physiologic transfusion triggers, or their response to packed red blood cell (pRBC) transfusions are limited. OBJECTIVES This study aimed to evaluate the interactions between Hb, mixed/central venous oxygen saturation (SvO 2 ) and lactate levels as well as their changes (ΔSvO 2 , Δlactate) in response to pRBC transfusion in cardiac surgery patients. DESIGN Retrospective exploratory data analysis. SETTING A 22-bed intensive care unit (ICU) at a single tertiary academic centre and university hospital in Austria. PATIENTS Adult (age ≥ 18 years) patients who underwent cardiac surgery. MAIN OUTCOME MEASURES Pearson correlation coefficients ( r ) and coefficients of determination ( r2 ) between Hb, mixed/central venous oxygen saturation (SvO 2 ), and lactate levels. Pearson correlation coefficients ( r ) and coefficients of determination ( r2 ) between ΔSvO 2 , Δlactate and pretransfusion Hb. RESULTS A total of 5025 cardiac surgery patients, in whom 20 542 blood gas analyses were performed, were included in the final analysis. Correlations between Hb levels and SvO 2 ( r2 = 0.026, P < 0.001) and between Hb and lactate levels ( r2 = 0.001, P < 0.001) were statistically significant but weak overall. No correlations were found between ΔSvO 2 ( r2 = 0.002, P = 0.13) or Δlactate ( r2 = 0.003, P = 0.087) and pretransfusion Hb levels. CONCLUSIONS Hb, SvO 2 and lactate levels were only weakly correlated with each other, and changes in SvO 2 and lactate levels in response to pRBC transfusion did not correlate with pretransfusion Hb. Our findings question the usefulness of SvO 2 and lactate levels as physiologic transfusion triggers to guide transfusion practice in cardiac surgery patients. TRIAL REGISTRATION Johannes Kepler University Ethics Committee Study Reference Number 1063/2023.
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Affiliation(s)
- Matthias Noitz
- From the Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria (MN, RB, CS, TT, MWD, JM), Department of Anesthesiology and Intensive Care Medicine, University Hospital Center Zagreb - Rebro, Zagreb, Croatia (TTM, RB), Research Unit Medical Informatics, RISC Software GmbH, Hagenberg i.M., Austria (AM), Department of Cardiothoracic and Vascular Surgery, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria (AZ), Medical Faculty, Johannes Kepler University Linz, Linz, Austria (MN, RB, CS, TT, AZ, MWD, JM)
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Yau P, Liu B, Friedmann P, Lipsitz E, Koleilat I. The effect of incremental increases in the number of packed red blood cell units transfused on perioperative outcomes in open abdominal aortic aneurysm repair. Vascular 2025; 33:504-510. [PMID: 38872373 DOI: 10.1177/17085381241260925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
IntroductionDespite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications.MethodsPatients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications.ResultsOf 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications.DiscussionThere appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.
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Affiliation(s)
- Patricia Yau
- Department of Cardiothoracic and Vascular Surgery, Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Bryce Liu
- Department of Cardiothoracic and Vascular Surgery, Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Patricia Friedmann
- Department of Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Evan Lipsitz
- Department of Cardiothoracic and Vascular Surgery, Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Issam Koleilat
- Robert Wood Johnson, Barnabas Health, Community Medical Center, Toms River, NJ, USA
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Chang H, Garg K, Veith FJ, Basman C, Cho JS, Zeeshan M, Mateo RB, Ebanks M, Rockman CB. Moderate-to-Severe Preoperative Anemia is Associated with Increased Postoperative Myocardial Infarction and Mortality in Patients Undergoing Transcarotid Artery Revascularization. Ann Vasc Surg 2025; 115:43-52. [PMID: 40049547 DOI: 10.1016/j.avsg.2025.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2025] [Revised: 02/21/2025] [Accepted: 02/22/2025] [Indexed: 03/30/2025]
Abstract
BACKGROUND While preoperative anemia is prevalent among surgical patients, its impact on patients undergoing transcarotid artery revascularization (TCAR) remains poorly understood. This study aims to assess the relationship between the severity of preoperative anemia and outcomes following TCAR. METHODS A retrospective analysis of the Vascular Quality Initiative database (2016-2021) was performed to identify patients who underwent TCAR for carotid stenosis. Anemia was defined according to World Health Organization guidelines as a hemoglobin (Hb) level <12 g/dL in females and <13 g/dL in males. The severity of anemia was further classified as mild (Hb: 10-11.9 g/dL in females and 11-12.9 g/dL in males) or moderate to severe (Hb < 10 g/dL in females and <11 g/dL in males). Patients were stratified into three cohorts as follows, based on the presence and severity of preoperative anemia: no anemia, mild anemia, and moderate-to-severe anemia. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital stroke, in-hospital death, myocardial infarction (MI), and prolonged postoperative hospitalization (>1 day). Univariable and multivariable logistic regression analyses were conducted to evaluate the association between the severity of preoperative anemia and clinical outcomes. RESULTS Among 21,648 patients who underwent TCAR, 4,240 (19.8%) had mild anemia, and 3,401 (15.8%) had moderate-to-severe anemia preoperatively. After adjusting for relevant clinical factors and confounders, moderate-to-severe preoperative anemia was associated with significantly increased odds of in-hospital MI (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI]: 1.53-3.74; P < 0.001), in-hospital death (aOR, 2.65; 95% CI: 1.62-4.34; P < 0.001), and 30-day mortality (aOR, 1.89; 95% CI: 1.32-2.72; P < 0.001) compared to nonanemic patients. Among patients with moderate-to-severe anemia, factors such as a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), urgent or emergent procedures, and symptomatic carotid stenosis were the strongest predictors of 30-day mortality. In contrast, mild anemia was not associated with increased odds of adverse postoperative outcomes compared to the nonanemic cohort. Preoperative anemia, regardless of severity, was not associated with an increased risk of postoperative stroke following TCAR. However, the severity of preoperative anemia was associated with a stepwise increase in the adjusted odds of prolonged hospitalization (aOR, 1.19 [mild anemia] and 1.57 [moderate-to-severe anemia]). CONCLUSION In this multi-institutional retrospective study of patients undergoing TCAR, moderate-to-severe preoperative anemia was independently associated with higher adjusted odds of in-hospital MI, in-hospital death, and 30-day mortality, without an increased risk of postoperative stroke. These findings highlight moderate-to-severe preoperative anemia as a potential independent prognostic marker for identifying high-risk patients. Furthermore, incorporating the severity of anemia into preoperative risk stratification may aid in tailoring perioperative cardiac assessment and optimization strategies, potentially mitigating the risk of adverse outcomes following TCAR.
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Affiliation(s)
- Heepeel Chang
- Department of Vascular Surgery, Hackensack University Medical Center, Hackensack, NJ.
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Craig Basman
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, NJ
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
| | - Muhammad Zeeshan
- Section of Vascular Surgery, Department of Surgery, Barnes Jewish Hospital / Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Romeo B Mateo
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY
| | - Mikaiel Ebanks
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY
| | - Caron B Rockman
- Department of Vascular Surgery, Hackensack University Medical Center, Hackensack, NJ
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Li Z, Yao W, Wang J, Wang X, Luo S, Zhang P. Impact of restrictive versus liberal transfusion strategy on outcomes in patients undergoing surgery for spinal metastasis: a propensity score-matched analysis. Neurosurg Rev 2025; 48:450. [PMID: 40434521 DOI: 10.1007/s10143-025-03598-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2025] [Revised: 04/06/2025] [Accepted: 05/16/2025] [Indexed: 05/29/2025]
Abstract
BACKGROUND Spinal metastasis, common in advanced cancer cases, frequently require surgical intervention to improve quality of life by stabilizing the spine and alleviating neural compression. The perioperative transfusion strategies in this setting is under debate. Evidence specific to spinal metastasis surgery remains limited. This study aimed to evaluate the effects of liberal versus restrictive transfusion strategy on postoperative outcomes in patients undergoing surgery for spinal metastasis. METHODS A retrospective study was conducted with patients who underwent surgery for spinal metastasis. Using propensity score matching (PSM), patients were matched into restrictive and liberal transfusion groups, adjusting for baseline characteristics. Postoperative outcomes, including 30-day complications, hospital stay, and survival rates at 3 months and 1 year, were compared between the groups. RESULTS Among 483 patients, 303 received at least one unit of red blood cells during hospitalization. Of these, 125 (41.3%) were in the restrictive transfusion group, and 178 (58.7%) in the liberal transfusion group. After PSM, 70 patients in each group were matched 1:1, ensuring comparable baseline characteristics. Post-matching analysis revealed no significant differences between the groups in key outcomes: 3-month survival (84% vs. 83%, P = 0.820), 1-year survival (46% vs. 51%, P = 0.499), 30-day postoperative complications (19% vs. 23%, P = 0.532), and median length of stay (15 [IQR, 11-18] days vs. 13 [IQR, 11-17] days, P = 0.316). CONCLUSIONS Our study supports using a restrictive transfusion strategy with a target nadir Hb level of 7-8 g/dL for spinal metastasis surgery. This approach ensures adequate oxygen delivery while minimizing unnecessary transfusions and associated risks. Future studies should validate these findings and further explore patient-centered outcomes to refine transfusion strategy in high-risk oncology patients. CLINICAL TRIAL NUMBER Not applicable.
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Affiliation(s)
- Zhehuang Li
- Department of Musculoskeletal Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Weitao Yao
- Department of Musculoskeletal Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Jiaqiang Wang
- Department of Musculoskeletal Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Xin Wang
- Department of Musculoskeletal Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Suxia Luo
- Department of Medical Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Peng Zhang
- Department of Musculoskeletal Oncology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.
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Maxey-Jones C, Seelhammer TG, Arabia FA, Cho B, Cardonell B, Smith D, Leo V, Dias J, Shore-Lesserson L, Hartmann J. TEG® 6s-Guided Algorithm for Optimizing Patient Blood Management in Cardiovascular Surgery: Systematic Literature Review and Expert Opinion. J Cardiothorac Vasc Anesth 2025; 39:1162-1172. [PMID: 40016048 DOI: 10.1053/j.jvca.2025.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 01/24/2025] [Accepted: 02/06/2025] [Indexed: 03/01/2025]
Abstract
OBJECTIVES To propose a comprehensive TEG 6s-based intraoperative and/or immediately postoperative treatment algorithm for bleeding patients undergoing cardiac surgery. To achieve this, TEG-based treatment algorithms in cardiac surgery were evaluated through a literature review and structured expert opinion. DESIGN Systematic literature review. SETTING Cardiac surgery. PARTICIPANTS Adult patients undergoing cardiac surgery with intraoperative and/or immediately postoperative bleeding. INTERVENTIONS TEG-guided transfusion algorithm. MEASUREMENTS AND MAIN RESULTS A literature search was conducted for original studies reporting TEG-based treatment algorithms in cardiac surgery settings. Of 304 identified manuscripts, fourteen met all inclusion criteria, with two further articles identified through authors' suggestions. There is limited evidence describing the use of TEG 6s assays in cardiac surgery with only one study reporting a dedicated algorithm using the TEG 6s device at a non-US center. Two additional studies assessed TEG 6s assays. The remaining manuscripts reported algorithms based on the TEG 5000 device. Following the author's review of the available data, and feedback from expert opinion, a simple transfusion algorithm was proposed as an initial framework for developing a TEG 6s-based protocol with consideration for the 2021 Society of Thoracic Surgery/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology/Society for the Advancement of Patient Blood Management Patient Blood Management Guidelines. CONCLUSIONS A new algorithm for cardiac surgery based on TEG 6s assays has been proposed based on the available evidence and expert opinion for research alignment and clinical validation.
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Affiliation(s)
| | | | | | - Brian Cho
- Johns Hopkins University, Baltimore, MD
| | | | | | | | | | - Linda Shore-Lesserson
- Northwell, New Hyde Park, NY; and Anesthesiology, North Shore University Hospital, Manhasset, NY
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Bhatt HV, Hu Y, Lin HM, Egorova N, Ouyang Y, Levin MA. Comparison of Perioperative Outcomes for Transfusion of Hemoconcentrated Bypass Versus Cell Saver Blood in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2025; 39:1173-1179. [PMID: 39984367 DOI: 10.1053/j.jvca.2025.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 01/22/2025] [Accepted: 01/27/2025] [Indexed: 02/23/2025]
Abstract
OBJECTIVE Hemoconcentration and cell saver use are blood conservation techniques that are often used in cardiac surgery to salvage the patient's own blood to reduce autologous transfusion. The purpose of this study was to examine the perioperative outcomes including transfusion rates in cardiac surgical patients receiving hemoconcentrated blood versus cell saver blood via retrospective chart review. We hypothesized that hemoconcentration would have better patient outcomes, including reduced transfusion rates, compared to only cell salvage technique. DESIGN Single-center, retrospective chart review case-control study SETTING: Cardiac operating room of a tertiary care center PARTICIPANTS: Patients over 18 years old who underwent elective open-heart surgery with cardiopulmonary bypass between January 2015 to January 2018. Patients for emergencies, off-pump cases, transplants, and reoperations and with a need for second bypass were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The specific outcomes assessed include perioperative transfusion of packed red blood cells and blood products, intensive care unit (ICU) length of stay, hospital length of stay, and surgical site infections. Patient characteristics such as ejection fraction and comorbidities, pulmonary hypertension, atrial fibrillation history, and coagulation dysfunction were also analyzed. Propensity score matching was done to balance the covariates between the groups. The differences for each outcome outlined above were calculated. Of the 744 observations, 735 were used for analysis after propensity matching. Postoperative ICU red blood cell transfusions recorded a mean difference of -0.37 (95% CI: -0.78, 0.04). Postoperative ICU platelets and fresh frozen plasma recorded mean differences of -0.01 (95% CI: -0.11, 0.09) and -0.08 (95% CI: -0.19, 0.03), respectively. There were no significant differences in outcomes in bivariate- and covariate-adjusted models. CONCLUSIONS There is no significant difference in postoperative blood transfusion rates in hemoconcentrated versus cell saver blood usage in cardiac surgery patients. Further studies are needed to analyze specific quantities and ratios of hemoconcentrated and cell saver blood used in these patients for a more clinically relevant analysis. This would allow incorporation of hemoconcentration and cell saver techniques into better blood conservation processes and guide overall transfusion strategies to reduce transfusion rates of blood and blood products in cardiac surgical patients.
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Affiliation(s)
- Himani V Bhatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Young Hu
- Department of Family Medicine, Stamford Hospital/Columbia University, Stamford, CT
| | - Hung-Mo Lin
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuxia Ouyang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Tian B, Chen C, Huang C, Chen Q, Cheng J, Wu H, Wang J, Mo J, Zhong G, Chen X. Blood transfusion in percutaneous left atrial appendage occlusion: a nationwide analysis of incidence, predictors, and outcomes. BMC Cardiovasc Disord 2025; 25:303. [PMID: 40263982 PMCID: PMC12016412 DOI: 10.1186/s12872-025-04662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 03/12/2025] [Indexed: 04/24/2025] Open
Abstract
BACKGROUND Patients with atrial fibrillation (AF) may benefit from PLAAO, a method proven to reduce the risk of stroke. However, the risk of requiring blood transfusion during the perioperative period has not been adequately evaluated. OBJECTIVES Using a comprehensive nationwide database, this study aimed to evaluate the frequency of transfusion events, identify contributing factors, and assess clinical outcomes in individuals who underwent PLAAO. METHODS A retrospective evaluation of 61,445 PLAAO procedures, documented in the Nationwide Inpatient Sample database from 2015 to 2019, was conducted. The analysis compared patient characteristics, underlying conditions, medical complications, institutional features, and clinical results between groups requiring and not requiring transfusion support. A multivariable logistic regression model was used to identify key predictors of blood transfusion. RESULTS Transfusion support was necessary in 1.8% of procedures (1,090/61,445), with a decrease from 5.0% in 2015 to 1.7% by 2019. Independent factors associated with an increased need for transfusion included female sex, pre-existing conditions (chronic blood loss anemia, coagulopathy, fluid and electrolyte disorders, metastatic cancer, other neurological disorders, and peripheral vascular disorders), and complications (hemorrhage/seroma/hematoma, postoperative shock, urinary tract infections, gastrointestinal bleeding, acute heart failure, dialysis). Protective factors included elective admission and hospital location in the Midwest/North central, South, or West regions. The transfusion group experienced significantly poorer outcomes, with higher mortality (3.2% vs. 0.1%, P < 0.05), longer hospitalizations (median 3 vs. 1 day, P < 0.05), and greater hospital expenses (median $159,635 vs. $101,953, P < 0.05). CONCLUSION Patients undergoing PLAAO who require blood transfusion face significantly higher risks of death, extended hospital stays, and increased healthcare expenses. A thorough pre-procedure risk assessment could improve patient selection and minimize transfusion requirements.
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Affiliation(s)
- Binbin Tian
- Department of Critical Care Medicine, Central People's Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of South University of Science and Technology, Shenzhen, 518020, China
| | - Chengzhao Huang
- Department of Critical Care Medicine, Central People's Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China
| | - Qiuqiang Chen
- Department of Critical Care Medicine, Central People's Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China
| | - Junfen Cheng
- Department of Respiration, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, 524002, China
| | - Haiqiang Wu
- Department of Neurosurgery II, Central People's Hospital of Zhanjiang, Zhanjiang, Guangdong, 524045, China
| | - Jian Wang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Junde Mo
- Department of Critical Care Medicine, Central People's Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China.
| | - Guorong Zhong
- Department of Critical Care Medicine, Central People's Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China.
| | - Xiaozhuo Chen
- Department of Critical Care Medicine, Central People's Hospital of Zhanjiang, Zhanjiang, 524045, Guangdong, China.
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Lee SH, Kim JE, Lee JH, Jung JS, Son HS, Kim HJ. Perioperative Red Blood Cell Transfusion and Long-Term Mortality in Coronary Artery Bypass Grafting: On-Pump and Off-Pump Analysis. J Clin Med 2025; 14:2662. [PMID: 40283492 PMCID: PMC12027956 DOI: 10.3390/jcm14082662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2025] [Revised: 04/02/2025] [Accepted: 04/05/2025] [Indexed: 04/29/2025] Open
Abstract
Background/Objectives: The impact of different coronary artery bypass grafting (CABG) strategies, particularly on-pump versus off-pump techniques, on red blood cell (RBC) transfusions and their associated outcomes has not been fully investigated. This study aims to evaluate the association between RBC transfusion and survival in CABG patients, focusing on-pump strategy. Methods: Data from CABG patients were retrieved from the National Health Insurance Service database (2003 to 2019). Perioperative RBC transfusions were classified into three groups: no transfusion, RBC 1, and RBC ≥ 2 units. The primary endpoint was all-cause mortality rate. Subgroup analysis assessed the impact of RBC transfusion on mortality across the conventional on-pump (CCAB) and off-pump (OPCAB) groups. Results: Among the 6150 participants who underwent CABG, 2028 underwent CCAB and 4122 underwent OPCAB. The mean age was 66.2 ± 9.7 years, with a mean follow-up of 2.9 (2.53-3.35) years. Multivariable analysis showed a significant association between transfusion of ≥2 RBC units and increased mortality risk (HR 2.34 [1.65-3.32], p < 0.001). Subgroup analysis showed a similar trend in both CCAB and OPCAB groups (p for interaction = 0.2). Transfusion of ≥2 units significantly increased mortality in OPCAB (HR 2.28 [1.55-3.37], p < 0.001) but not in CCAB (HR 2.96 [0.97-9.06], p = 0.057). OPCAB and surgery at large volume center was associated with a reduced risk of RBC transfusion (p < 0.01). Conclusions: Increased RBC transfusion is associated with higher long-term mortality in patients undergoing CABG. Based on a large cohort predominantly consisting of OPCAB patients, OPCAB is associated with decreased RBC transfusion requirements.
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Affiliation(s)
| | | | | | | | - Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (S.H.L.); (J.E.K.); (J.H.L.); (J.S.J.)
| | - Hee-Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, College of Medicine, Korea University, Seoul 02841, Republic of Korea; (S.H.L.); (J.E.K.); (J.H.L.); (J.S.J.)
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Jain A, Aifuwa E, Bienenstock R, Kar S, Spirollari E, Sacknovitz A, Mashiach E, Koyfman F, Chong J, Medicherla C, Gandhi CD, Al-Mufti F. Outcomes of Blood Transfusions in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Population-Based Cross-Sectional Study of 47,835 Patients. Brain Sci 2025; 15:386. [PMID: 40309858 PMCID: PMC12025927 DOI: 10.3390/brainsci15040386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2025] [Revised: 03/27/2025] [Accepted: 03/31/2025] [Indexed: 05/02/2025] Open
Abstract
Background/Objectives: Despite advances, large vessel occlusion strokes (LVO) remain associated with significant morbidity. Recent studies have suggested that blood transfusions may help manage critically ill LVO patients. We sought to evaluate the patient characteristics, complications, and clinical outcomes associated with blood transfusions in acute ischemic stroke (AIS) patients undergoing endovascular thrombectomy. Methods: A query of the 2016-2019 National Inpatient Sample was conducted to identify AIS patients who underwent endovascular thrombectomy, using International Classification of Disease 10th Revision diagnostic codes. Demographic, clinical characteristics, severity of presentation, complications, and outcomes were analyzed. Multivariate binary logistic regression was used to assess complications, length of stay (LOS), discharge disposition, and inpatient mortality. Results: A total of 47,835 AIS patients undergoing endovascular thrombectomy were identified. Of these patients, 1215 (2.5%) received blood transfusions. After controlling for age, gender, National Institutes of Health Stroke Scale scores, Elixhauser Comorbidity Index, and location of stroke, blood transfusions were significant positive predictors for higher rates of inpatient death (OR: 1.96; 95% CI: 1.681, 2.286; p < 0.001), lower rates of routine discharge (OR: 0.425; 95% CI: 0.342, 0.527; p < 0.001), and prolonged LOS (OR: 2.928; 95% CI: 2.572, 3.333; p < 0.001). Conclusions: Blood transfusions in AIS patients receiving endovascular thrombectomy are associated with elevated complication rates, extended hospital stays, and increased mortality, even after for controlling for predictors of poor outcome. Understanding the broader effects of blood transfusions in AIS patients is essential to ensure that the balance between potential benefits and risks upholds best care practice for all patients.
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Affiliation(s)
- Ankita Jain
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA;
| | - Eseiwi Aifuwa
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
| | - Raphael Bienenstock
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
| | - Shayna Kar
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA; (S.K.); (F.K.); (J.C.); (C.M.)
| | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA;
| | - Ariel Sacknovitz
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA;
| | - Elad Mashiach
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA;
| | - Feliks Koyfman
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA; (S.K.); (F.K.); (J.C.); (C.M.)
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA; (S.K.); (F.K.); (J.C.); (C.M.)
| | - Chaitanya Medicherla
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA; (S.K.); (F.K.); (J.C.); (C.M.)
| | - Chirag D. Gandhi
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA;
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA; (A.J.); (E.A.); (R.B.); (E.S.); (A.S.); (C.D.G.)
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA; (S.K.); (F.K.); (J.C.); (C.M.)
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11
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Sebt V, Sharifi S, Meysamie A, Saberi K. Acute Normovolemic Hemodilution Significantly Reduces RBC Transfusion and Lactic Acidosis Following Cardiac Surgery-A Propensity-Matched Study. Ann Card Anaesth 2025; 28:136-142. [PMID: 40237659 PMCID: PMC12058070 DOI: 10.4103/aca.aca_192_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2024] [Revised: 10/10/2024] [Accepted: 10/24/2024] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND Bleeding represents a major complication in heart surgeries. However, even small amounts of allogeneic blood are associated with reduced long-term survival and short-term complications. Acute normovolemic hemodilution (ANH) serves as a viable alternative, but its effectiveness and safety remain controversial. OBJECTIVE We aimed to clarify the effects of mild-volume ANH on blood transfusions and short-term complications following heart surgeries. METHODS This was a quasi-experimental study in a referral center on 2271 patients. We performed an extensive propensity-score matching to mitigate the lack of random assignment and potential selection bias. This resulted in 778 patients with no significant differences in 28 variables, including clinical, paraclinical, and operative features. RESULTS ANH significantly reduced the rate of RBC transfusion by 16% (50.9% vs. 60.9%; RR: 0.84; P = 0.006) and the number of transfused RBCs by 0.24 units (0.96 ± 1.32 vs. 1.20 ± 1.39; P = 0.013) but did not affect the transfusion of FFP or platelets. Furthermore, ANH significantly lowered the incidence of lactic acidosis by 53% (6.8 vs. 11.3%; RR: 0.47; P < 0.001) but had no notable impact on other short-term outcomes following heart surgery, including mortality, re-intubation, re-exploration, delayed sternal closure, length of ICU stay, or duration of mechanical ventilation. CONCLUSION Mild-volume ANH significantly reduced the rate and amount of perioperative RBC transfusions, as well as the incidence of lactic acidosis following heart surgery. ANH did not affect the incidence of other complications during hospitalization. IMPLICATION This suggests that ANH could be a safe and beneficial blood conservation technique. Further randomized clinical trials are needed to evaluate its effects.
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Affiliation(s)
- Vala Sebt
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahnaz Sharifi
- Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alipasha Meysamie
- Department of Community and Preventive Medicine, Medical Faculty, Tehran University of Medical Sciences, Tehran, Iran
| | - Kianoush Saberi
- Department of Anesthesiology, Medical Faculty, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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12
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Karkouti K, Callum JL, Bartoszko J, Tanaka KA, Knaub S, Brar S, Ghadimi K, Rochon A, Mullane D, Couture EJ, Lin Y, Harle C, Zeller M, Tran DTT, Solomon C, Rao V, Law M, Butt AL, Chen EP, Martins MR, Saha T, Shih AW, Vézina MC, Moussa F, Pereira Cezar Zamper R, Syed S, Buyukdere H, Werner S, Grewal D, Wong D, Vandyck KB, Tanzola R, Hughes B, Royer O, Wong S, Levy JH. Prothrombin Complex Concentrate vs Frozen Plasma for Coagulopathic Bleeding in Cardiac Surgery: The FARES-II Multicenter Randomized Clinical Trial. JAMA 2025:2832096. [PMID: 40156829 PMCID: PMC11955085 DOI: 10.1001/jama.2025.3501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2025] [Accepted: 03/05/2025] [Indexed: 04/01/2025]
Abstract
Importance Excessive bleeding is a common and prognostically important complication of cardiac surgery. For bleeding related to coagulation factor deficiency, frozen plasma is the most used therapy. Preliminary trials indicate that 4-factor prothrombin complex concentrate (PCC) may be a suitable alternative. Objective To compare the efficacy and safety of PCC with frozen plasma in patients undergoing cardiac surgery with coagulopathic bleeding. Design, Setting, and Participants Unblinded randomized noninferiority controlled clinical trial at 12 hospitals in Canada and the US involving adults (≥18 years) who had developed bleeding related to coagulation factor deficiency after termination of cardiopulmonary bypass during surgery (November 30, 2022, to May 28, 2024). Final 30-day follow-up visit was completed on June 28, 2024. Intervention A total of 265 patients were randomized to receive PCC (1500 IU ≤60 kg; 2000 IU >60 kg) and 263, frozen plasma (3 U ≤60 kg; 4 U >60 kg) in the operating room. A second dose was allowed over the next 24 hours if indicated; thereafter, only frozen plasma could be used. Main Outcomes and Measures The primary outcome was hemostatic response (effective if no hemostatic interventions occurred from 60 minutes to 24 hours after treatment initiation). The noninferiority of PCC vs frozen plasma was assessed using a 10% margin and a 1-sided α of .025, with subsequent testing for superiority if noninferiority was demonstrated. Secondary outcomes included allogeneic blood transfusions and adverse events. Patients were followed up until postoperative day 30. Results Of 538 enrolled patients, 420 patients (median age, 66 years [IQR, 57-73 years]; 74%, male; 10%, Asian; 1%, Black; and 65%, White) were included in the primary analysis; of those, 296 (70%) underwent complex surgeries. Compared with the 207 patients in the frozen plasma group, the 213 patients in the PCC group had higher hemostatic effectiveness (166 [77.9%] vs 125 [60.4%]; difference, 17.6%; 95% CI, 8.7%-26.4%; P < .001 for noninferiority and superiority) and had received fewer transfusions including red blood cells, platelets, and noninvestigational frozen plasma units (mean, 6.6 units; 95% CI, 5.7-7.7 vs 9.3 units; 95% CI, 8.0-10.8; difference, 2.7; 95% CI, 1.0-4.4; P = .002). Seventy-seven patients (36.2%) in the PCC group vs 98 (47.3%) in the frozen plasma group experienced serious adverse events (relative risk [RR], 0.76; 95% CI, 0.61-0.96; P = .02). Twenty-two patients (10.3%) in the PCC group and 39 (18.8%) in the frozen plasma group had acute kidney injury (RR, 0.55; 95% CI, 0.34-0.89; P = .02). Conclusions and Relevance In this unblinded randomized clinical trial, PCC had superior hemostatic efficacy and safety advantages to frozen plasma among patients requiring coagulation factor replacement for bleeding during cardiac surgery. Trial Registration ClinicalTrials.gov Identifier: NCT05523297.
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Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie L. Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen’s University, Kingston, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kenichi A. Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City
| | | | - Sukhpal Brar
- Department of Anesthesiology and Perioperative Medicine, Royal Columbian Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, Canada
| | - Kamrouz Ghadimi
- Clinical Research Unit, Department of Anesthesiology & Critical Care, Duke University Health System, Durham, North Carolina
| | - Antoine Rochon
- Department of Anesthesia, University of Montreal, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Darren Mullane
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Harle
- London Health Sciences Centre, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Michelle Zeller
- Micheal G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Diem T. T. Tran
- Division of Cardiac Anesthesiology and Critical Care, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Vivek Rao
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Law
- Department of Anesthesiology and Perioperative Medicine, Royal Columbian Hospital, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, Canada
| | - Amir L. Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Edward P. Chen
- Cardiothoracic Surgery Division, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Maria Rosal Martins
- Department of Anesthesia, University of Montreal, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre and Queen’s University, Kingston, Ontario, Canada
| | - Andrew W. Shih
- Vancouver General Hospital, Vancouver, British Columbia, Canada
- Current affiliation: Department of Pathology and Molecular Medicine, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Marie-Claude Vézina
- Department of Anesthesiology, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Fuad Moussa
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Sunnybrook Health Sciences Centre, Schulich Heart Centre, Toronto, Ontario, Canada
| | | | - Summer Syed
- Department of Anesthesia, McMaster University, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada
- Department of Anesthesia, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Hakan Buyukdere
- Division of Hematopathology and Transfusion Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Deep Grewal
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Daniel Wong
- Division of Cardiac Surgery, Royal Columbian Hospital, New Westminster, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Kofi B. Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Robert Tanzola
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre and Queen’s University, Kingston, Ontario, Canada
| | - Bevan Hughes
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Olivier Royer
- Department of Anesthesiology, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Sophia Wong
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jerrold H. Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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Chang H, Veith FJ, Cho JS, Lui A, Laskowski IA, Mateo RB, Ventarola DJ, Babu S, Maldonado TS, Garg K. Impaired Pre-operative Ambulatory Capacity in Patients Undergoing Elective Endovascular Infrarenal Abdominal Aortic Aneurysm Repair is Associated with Increased Peri-operative Death. Eur J Vasc Endovasc Surg 2025; 69:432-439. [PMID: 39341419 DOI: 10.1016/j.ejvs.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 06/08/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVE While ambulatory capacity is a readily assessable clinical indicator of functional status, its association with outcomes after endovascular aneurysm repair (EVAR) remains underexplored. This study aimed to investigate the association between pre-operative ambulatory status and outcomes following elective EVAR. METHODS A retrospective review of the multi-institutional Vascular Quality Initiative database was conducted for all patients who underwent elective infrarenal EVAR from 2009 - 2022. Patients were categorised into independent ambulation and impaired ambulation groups. A propensity score matched analysis was performed to produce two well matched cohorts in a 1:1 ratio without replacement. The primary outcome was 30 day death. Secondary outcomes included one year survival and in hospital major complications. RESULTS Among 11 474 patients, 10 539 (91.8%) were independently ambulatory pre-operatively. Propensity score matching resulted in 885 matched pairs. The impaired ambulation group, although older (mean 77.6 vs. 76.3 years; p = .001), showed comparable baseline characteristics. Post-operatively, the impaired ambulation group had higher cumulative in hospital complications and death as well as 30 day death. Even after adjustment for age, impaired pre-operative ambulation was associated with increased in hospital and 30 day death (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.26 - 3.95; p = .006). Multivariable analysis demonstrated increasing cumulative risk of 30 day death in the setting of impaired pre-operative ambulatory status with age > 75 years requiring post-operative red blood cell transfusion > 2 units (HR 5.75, 95% CI 2.09 - 15.88; p < .001). Beyond 30 days, impaired pre-operative ambulation was not associated with increased one year death (HR 1.09, 95% CI 0.81 - 1.48; p = .57). CONCLUSION Among patients who underwent elective infrarenal EVAR in this matched analysis, impaired pre-operative ambulatory capacity was associated with an increased risk of in hospital and 30 day death, further compounded by advanced age and post-operative transfusion. As such, a threshold higher than the traditional size criteria should be considered in shared decision making when determining options for the management of abdominal aortic aneurysm in this high risk cohort.
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Affiliation(s)
- Heepeel Chang
- Department of Vascular Surgery, Hackensack University Medical Centre, Hackensack, NJ, USA.
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Centre, New York, NY, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Centre and Case Western Reserve University, Cleveland, OH, USA
| | - Aiden Lui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Igor A Laskowski
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Centre/New York Medical College, Valhalla, NY, USA
| | - Romeo B Mateo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Centre/New York Medical College, Valhalla, NY, USA
| | - Daniel J Ventarola
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Centre/New York Medical College, Valhalla, NY, USA
| | - Sateesh Babu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Centre/New York Medical College, Valhalla, NY, USA
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Centre, New York, NY, USA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Centre, New York, NY, USA
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14
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Bagaria V, Badragiri L, Hiremath CS. Effect of blood conservation protocol on the utilisation of blood and outcome of patients undergoing open heart surgery. Perfusion 2025; 40:450-459. [PMID: 38491948 DOI: 10.1177/02676591241239838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Cardiac surgery is fraught with increased consumption of blood and blood products. Various strategies for blood conservation have been described. Our aim was to study the impact of a structured blood conservation protocol (BCP) on the utilization of blood and patient outcome. METHODS Retrospective analysis of prospectively collected data comparing adult patients undergoing open heart surgery with BCP with those undergoing surgery without BCP. The primary objective was to compare the amount of blood utilized and the hematocrit at discharge. The secondary objective was to compare the parameters of patient outcomes. The level of significance was set at 0.05. RESULTS The proportion of patients requiring transfusion (19.1% [9/47] vs 58.9% [33/56]; p < 0.001) and the quantity of blood transfused (12 units vs 45 units; p 0.003) in the BCP group was significantly lower. Interestingly, the hematocrit level at discharge was comparable between the groups (30.9 (4.8) versus 31.8 (2.4), p-0.671). The average cost incurred for transfusing blood in the BCP group was ₹ 370.2 as compared to ₹1165.1 in the other (p < 0.001). BCP reduced the odds of overall blood transfusion by 79.8% (OR 0.202 (0.084-0.485); p < 0.001) and intraoperative blood transfusion by 95.3% (OR 0.047 (0.010-0.213); p < 0.001). The morbidity and mortality were comparable between the groups. CONCLUSION Implementing a structured blood conservation protocol in patients undergoing open heart surgery significantly reduces the need for blood transfusion. It also has a promising impact on patient recovery after surgery and significant positive cost implications.
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Affiliation(s)
- Vivek Bagaria
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
- Department of Congenital Cardiac Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lahari Badragiri
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - C S Hiremath
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
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Starcevic Z, Zrno-Mihaljevic M, Gasparovic H, Pasalic M, Petricevic M, Goerlinger K, Petricevic M. Perioperative Changes in Hemostatic Properties as Assessed by Multiplate, Siemens PFA-200, and ROTEM-A Comparative Study. J Clin Med 2025; 14:1640. [PMID: 40095585 PMCID: PMC11900509 DOI: 10.3390/jcm14051640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Revised: 02/11/2025] [Accepted: 02/20/2025] [Indexed: 03/19/2025] Open
Abstract
Objectives: This study sought to determine the platelet function and viscoelastic blood properties in the pre- and postoperative period using three different point-of-care (POC) devices (Multiplate®, Siemens PFA-200® and ROTEM®). We aimed to investigate the association between preoperative POC test results and bleeding outcomes. Postoperative changes in blood hemostatic properties were also evaluated, as well as the agreement between two platelet function analyzers and rotational thromboelastometry parameters. Methods: The study was conducted in a prospective observational fashion. Patients undergoing elective coronary artery bypass graft surgery (CABG) were enrolled. Hemostatic blood properties were assessed using three different POC devices; two platelet function analyzers were used: (1) Impedance aggregometry (Multiplate®) with the arachidonic acid (ASPI) test and adenosine diphosphate (ADP) test. (2) The Siemens INNOVANCE® PFA-200 System with the following assays: the PFA Collagen/EPI test, PFA Collagen/ADP test, and the INNOVANCE® PFA P2Y test. Viscoelastic blood properties were assessed using ROTEM® delta (TEM Innovations GmbH, Munich, Germany). POC tests were performed simultaneously at two different time points: (1) before surgery and (2) on postoperative day 4, respectively. The primary outcome was defined as amounts of perioperative bleeding and transfusion requirements, classified according to the universal definition for perioperative bleeding (UDPB) score. Results: The study recruited a total number of 63 patients undergoing elective isolated coronary artery bypass graft surgery (CABG). Based on the packed red blood cell (PRBC) transfusion requirements, patients with excessive bleeding were not just only frequently transfused (87.5% vs. 48.9%, p = 0.007) but were also transfused with higher amounts of PRBCs (1338.75 mL ± SD 1416.49 vs. 289.36 mL ± 373.07, p < 0.001). The FIBTEM A30 results significantly correlated with excessive bleeding (Correlation Coefficient Rho = -0.280, p = 0.028). Regression analysis revealed FIBTEM A 30 as a strongest predictor of 24 h chest tube output (CTO) (R Square 0.108, p = 0.009). The receiver operating characteristics curve (ROC) analysis showed that a preoperative FIBTEM A30 < 10.86 mm predicted excessive bleeding with 94% sensitivity and 50% specificity (ROC AUC 68.4%). The multiplate ASPI test results were significantly higher (35.24 AUC ± SD 22.24 vs. 19.43 AUC ± SD 10.74) and the proportion of Aspirin responders was significantly lower (42.4% vs. 76.7%, p = 0.006) in patients considered to have insignificant bleeding. On postoperative day 4, we found platelet hyperreactivity in the ASPItest coupled with a ROTEM-documented shift towards hypercoagulability. Conclusions: Modern hemostatic management and perioperative antiplatelet therapy (APT) administration/discontinuation management should be guided by thromboelastometry and platelet function testing. Prospective interventional trials are necessary to validate such an approach in multicentric studies.
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Affiliation(s)
- Zrinka Starcevic
- Department of Cardiac Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (Z.S.); (M.Z.-M.); (H.G.)
| | - Martina Zrno-Mihaljevic
- Department of Cardiac Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (Z.S.); (M.Z.-M.); (H.G.)
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (Z.S.); (M.Z.-M.); (H.G.)
| | - Marijan Pasalic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Mirna Petricevic
- Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Klaus Goerlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45127 Essen, Germany;
- Medical Department, Tem Innovations, 81829 Munich, Germany
| | - Mate Petricevic
- Department of Health Studies, University of Split, 21000 Split, Croatia;
- School of Medicine, University Hospital of Split, University of Split, 21000 Split, Croatia
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Ong BJA, See Tow HX, Fong ATW, Ling RR, Shekar K, Teoh K, Ti LK, MacLaren G, Fan BE, Ramanathan K. Monitoring Hemostatic Function during Cardiac Surgery with Point-of-Care Viscoelastic Assays: A Narrative Review. Semin Thromb Hemost 2025. [PMID: 39938563 DOI: 10.1055/s-0045-1802573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2025]
Abstract
Bleeding is a well-known and severe complication of cardiac surgery. Cardiopulmonary bypass, along with heparinization and hemodilution, is thought to affect all pathways of the hemostatic process, leading to excessive bleeding and worsened morbidity and mortality. The traditionally used standard laboratory tests (SLTs) were not designed for the surgical setting, have long turnaround times, and are poor predictors of bleeding. This review aims to give an overview of viscoelastic assays (VEAs), compare VEAs to conventional testing methods, and summarize the evidence for VEAs in cardiac surgery. A search of Medline via Pubmed, Scopus, and Embase yielded 2,868 papers, which we reviewed and summarized the key findings. VEAs such as rotational thromboelastometry and thromboelastography provide a quick turnaround, graphical, global impression of hemostasis in whole blood. VEAs allow for the analysis of specific contributors to the coagulation process and may facilitate cause-oriented hemostatic treatment and the development of treatment algorithms. VEAs have been found to have a high specificity and high negative predictive value for coagulopathic bleeding. Patients treated with VEA-based algorithms have been shown to have lower rates of bleeding, transfusion requirements, and exposure to allogeneic blood products. However, VEA-based algorithms have not demonstrated a mortality benefit and evidence for outcomes such as surgical re-exploration and hospital length of stay remains equivocal. In conclusion, VEAs have been shown to be comparable if not superior to SLTs in cardiac surgery. Further large-scale studies are needed to better evaluate the impact of VEAs on clinical outcomes.
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Affiliation(s)
- Brandon Jin An Ong
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Hui Xin See Tow
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Alyssa Tze Wei Fong
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Australia and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, Melbourne, Victoria, Australia
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Kiran Shekar
- Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia
- Faculty of Health, Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia
| | - Kristine Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Division of Adult Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Bingwen Eugene Fan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Hematology, Tan Tock Seng Hospital, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
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Mauney C, Etchill E, Rea A, Edwin Fonner C, Whitman G, Salenger R. What drives variability in postoperative cardiac surgery transfusion rates? J Thorac Cardiovasc Surg 2025; 169:667-674.e1. [PMID: 38331214 DOI: 10.1016/j.jtcvs.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Wide interhospital variation exists in cardiac surgical postoperative transfusion rates. We aimed to compare transfusion rates at 2 hospitals and identify the institutional practice factors, unrelated to patient or operative characteristics, associated with postoperative transfusion rates. METHODS Records for adult patients undergoing routine cardiac surgery at 2 hospitals (H and L) from February 2020 to August 2022 were analyzed. Patient and operative characteristics, preoperative and intensive care unit hemoglobin values, and postoperative transfusion rates were compared. Transfusion indication was recorded prospectively. Propensity matching was completed to assess comparability of patient populations. RESULTS After propensity matching patients at H and L on age, procedure type, predicted morbidity or mortality, crossclamp time, preoperative hypertension, preoperative heart failure, and preoperative stroke, 2111 patients remained, with similar characteristics except hypertension. Matched results showed no significant differences in mortality, reoperation, or other major outcomes. Hospital H transfused 36% of patients (mean postoperative hemoglobin [Hb] 10.5) with 1483 units of packed red blood cells whereas hospital L transfused 12% of patients (mean postoperative Hb 9.4) with 198 units of packed red blood cells (P < .001). For all patients with a Hb >7.5, hospital H versus L transfused 27% versus 0.9% (P < .001). Hospital L's sole transfusion indication for pretransfusion hemoglobin trigger >7.5 was bleeding versus hospital H, which had multiple indications. When Hb concentration alone was the indication for transfusion, the threshold at hospital H was <7.5 g/dL versus <6 g/dL at hospital L. CONCLUSIONS Variation in transfusion rates between hospitals H and L resulted from strict adherence at hospital L to a transfusion trigger of <6 g/dL with narrow indications for transfusions above that Hb concentration.
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Affiliation(s)
| | - Eric Etchill
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Amanda Rea
- Division of Cardiac Surgery, Department of Surgery, University of Maryland St Joseph Medical Center, Towson, Md
| | | | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Rawn Salenger
- Division of Cardiac Surgery, Department of Surgery, University of Maryland St Joseph Medical Center, Towson, Md; Department of Surgery, University of Maryland School of Medicine, Baltimore, Md.
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Salamate S, Bakhtiary F, Bayram A, Silaschi M, Akhavuz Ö, Doss M, Sirat S, Ahmad AES. Endoscopic Minimally Invasive Approach Versus Median Sternotomy for Multiple-Valve Surgery: A Propensity-Matched Analysis. Adv Ther 2025; 42:261-279. [PMID: 39520659 PMCID: PMC11782361 DOI: 10.1007/s12325-024-03008-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 09/23/2024] [Indexed: 11/16/2024]
Abstract
INTRODUCTION Endoscopic minimally invasive valve surgery is a promising alternative to valve surgery through median sternotomy. Our study compared the short-term outcomes of patients undergoing endoscopic minimally invasive multiple concomitant valve surgeries (MIMVS) with median sternotomy (MS). METHODS Demographic, clinical, and procedural data of all consecutive patients who underwent multiple-valve surgeries at two institutions in Germany from March of 2017 to March of 2023 were retrospectively collected. Patients were divided into two groups: MIMVS versus MS and their outcomes were compared before and after propensity score matching. Primary endpoint was the incidence of 30-day mortality. RESULTS A total of 317 patients were included in the study; 112 patients in each group were matched 1:1. MIMVS was performed on 123 patients. After propensity matching, 30-day mortality rates were 8% for MIMVS versus 12.5% for MS (p = 0.28). Median blood transfusion in the MIMVS group was 0 [0-3] vs 1 [0-4] in the MS group (p = 0.002). MIMVS was associated with similar cardiopulmonary bypass time 105.5 [79.8-124] versus 98 [68.8-130.3] mins and aortic cross clamping times 70 [53-80.3] versus 63.5 [46-90.3] mins (p values 0.9 and 0.76, respectively). Median intensive care and inhospital stays were similar between both groups (2 [1-4] vs 2 [1-5] days, p = 0.36, and 12 [8-17] vs 12.5 [9-21] days, p = 0.38). Incidences of intrathoracic bleeding, stroke, and acute kidney injury were similar in both groups. CONCLUSIONS In our experience, endoscopic minimally invasive multiple-valve surgeries through right anterior mini-thoracotomy is as feasible, safe, and effective as medial sternotomy in select patients.
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Affiliation(s)
- Saad Salamate
- Department of Cardiac Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Ali Bayram
- Division of Cardiac Surgery, Heart Centre Siegburg, Siegburg, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Ömür Akhavuz
- Department of Cardiac Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Mirko Doss
- Division of Cardiac Surgery, Heart Centre Siegburg, Siegburg, Germany
| | - Sami Sirat
- Division of Cardiac Surgery, Heart Centre Siegburg, Siegburg, Germany
| | - Ali El-Sayed Ahmad
- Department of Cardiac Surgery, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
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Ait-Tigrine S, Hullin R, Hoti E, Kirsch M, Tozzi P. Risk Estimation of Severe Primary Graft Dysfunction in Heart Transplant Recipients Using a Smartphone. Rev Cardiovasc Med 2025; 26:25170. [PMID: 39867199 PMCID: PMC11759961 DOI: 10.31083/rcm25170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 09/09/2024] [Accepted: 09/30/2024] [Indexed: 01/28/2025] Open
Abstract
Background Currently, there are no standardized guidelines for graft allocation in heart transplants (HTxs), particularly when considering organs from marginal donors and donors after cardiocirculatory arrest. This complexity highlights the need for an effective risk analysis tool for primary graft dysfunction (PGD), a severe complication in HTx. Existing score systems for predicting PGD lack superior predictive capability and are often too complex for routine clinical use. This study sought to develop a user-friendly score integrating variables from these systems to enhance the efficacy of the organ allocation process. Methods Severe PGD was defined as the need for mechanical circulatory support and/or death from an unknown etiology within the first 24 hours following HTx. We used a meta-analytical approach to create a derivation cohort to identify risk factors. We then applied a logistic regression analysis to generate an equation predicting severe PGD risk. We used our previous experience in HTx to create a validation cohort. Subsequently, we implemented the formula in a smartphone application. Results The meta-analysis comprising six studies revealed a 10.5% ( 95% confidence interval (CI): 5.3-12.4) incidence rate of severe PGD and related 30-day mortality of 38.6%. Eleven risk factors were identified: female donors, female donor to male recipient, undersized donor, donor age, recipient on ventricular assist device support, recipient on amiodarone treatment, recipient with diabetes and renal dysfunction, re-sternotomy, graft ischemic time, and bypass time. An equation to predict the risk, including the 11 parameters (GREF-11), was created using logistic regression models and validated based on our experience involving 116 patients. In our series, 29 recipients (25%) required extracorporeal membrane oxygenation support within 24 hours post-HTx. The overall 30-day mortality was 4.3%, 3.4%, and 6.8% in the non-PGD and severe PGD groups, respectively. The area under the receiver operating characteristic (AU-ROC) curve of the model in the validation cohort was 0.804. Conclusions The GREF-11 application should offer HTx teams several benefits, including standardized risk assessment and bedside clinical decision support, thereby helping minimize the risk of severe PGD post-HTx.
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Affiliation(s)
- Souhila Ait-Tigrine
- Internal Medicine, Lausanne University Hospital CHUV Lausanne, 1011 Lausanne, Switzerland
| | - Roger Hullin
- Cardiology, Lausanne University Hospital CHUV Lausanne, 1011 Lausanne, Switzerland
| | - Elsa Hoti
- Lausanne University School of Medicine, 1005 Lausanne, Switzerland
| | - Matthias Kirsch
- Cardiac Surgery, Lausanne University Hospital CHUV Lausanne, 1011 Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Cardiac Surgery, Lausanne University Hospital CHUV Lausanne, 1011 Lausanne, Switzerland
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20
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Budd AN, Parulkar SD, Carabini LM, McCarthy RJ. 4-Factor prothrombin complex concentrates and factor VIII inhibitor bypass activity use in cardiac surgery. Blood Coagul Fibrinolysis 2025; 36:18-25. [PMID: 39661523 DOI: 10.1097/mbc.0000000000001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 11/12/2024] [Indexed: 12/13/2024]
Abstract
OBJECTIVES The objective of this study was to compare total thromboembolic complications between 4-factor prothrombin complex concentrate (4F-PCC) with factor VIII inhibitor bypassing activity (FEIBA) when utilized during cardiac surgery. DESIGN A quasi-experimental analysis of retrospective data from consecutive patients. SETTING A tertiary care university hospital. PARTICIPANTS Patients undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Patients received either 4F-PCC or FEIBA after discontinuation of cardiopulmonary bypass and reversal of heparin with protamine. MEASUREMENTS AND MAIN RESULTS Medical records were reviewed for thromboembolic events (stroke, arterial or venous thrombosis, pulmonary embolism, myocardial infarction), acute kidney injury, ischemic bowel, death, duration of intensive care unit and hospital stay, clinical and surgical characteristics and blood product utilization. A comparison of the clinical and surgical variables demonstrated a mean effect size of 0.33 imbalance between groups that was reduced to 0.18 after propensity score weighting. The propensity scores weighted analysis found an incidence of composite thromboembolic events of 39% in the 4F-PCC ( n = 90) and 47% in the FEIBA ( n = 50) group, difference -8 (-24% to 12%), P = 0.13. Individual thromboembolic events, acute kidney injury, ischemic bowel, mortality, and length of intensive care unit or hospital stay was not different among groups. Patients who received FEIBA had greater chest tube drainage and received more cryoprecipitate intraoperatively. Patients who received 4F-PCC received more fresh frozen plasma transfusions postoperatively. CONCLUSIONS Among cardiac surgery patients, there was no difference in thromboembolic events between patients who received 4F-PCC or FEIBA when used as an adjunct to blood product administration.
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Affiliation(s)
- Ashley N Budd
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine
| | - Suraj D Parulkar
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine
| | - Louanne M Carabini
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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Douville NJ, Mathis M, Kheterpal S, Heung M, Schaub J, Naik A, Kretzler M. Perioperative Acute Kidney Injury: Diagnosis, Prediction, Prevention, and Treatment. Anesthesiology 2025; 142:180-201. [PMID: 39527650 PMCID: PMC11620328 DOI: 10.1097/aln.0000000000005215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 08/20/2024] [Indexed: 11/16/2024]
Abstract
In this review, the authors define acute kidney injury in the perioperative setting, describe the epidemiologic burden, discuss procedure-specific risk factors, detail principles of management, and highlight areas of ongoing controversy and research.
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Affiliation(s)
- Nicholas J. Douville
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan; Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Michael Mathis
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan; Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan; Department of Computational Medicine and Bioinformatics, Ann Arbor, Michigan
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Schaub
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Abhijit Naik
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthias Kretzler
- Department of Computational Medicine and Bioinformatics, Ann Arbor, Michigan; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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22
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Tatar M, Akdeniz CS, Zeybey U, Şahin S, Çiftçi Ç. Budget Impact Analysis of Implementing Patient Blood Management in the Cardiovascular Surgery Department of a Turkish Private Hospital. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:877-887. [PMID: 39720264 PMCID: PMC11668246 DOI: 10.2147/ceor.s481565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 12/02/2024] [Indexed: 12/26/2024] Open
Abstract
Purpose In cardiovascular surgeries, iron deficiency anemia and transfusion of blood products are associated with mortality and morbidity, prolonged hospital stay and poor patient outcomes. Patient blood management (PBM) is a patient-centered approach based on a 'three pillar' model that promotes optimum use of blood and blood products to improve outcomes. This study assessed the potential budget impact of implementing PBM in patients undergoing elective cardiovascular surgery in a private hospital in Turkey. Methods Two models were developed to estimate the hospital budget impact of PBM. The first model encompassed implementation of the first pillar of PBM, which proposes treatment of iron deficiency anemia before a surgical procedure. The second covered implementation of all three pillars of PBM. Budget impact was estimated from the number of avoided complications after treating iron deficiency anemia and reducing blood transfusions. Rates of complication (sepsis, myocardial infarction, renal failure and stroke) with and without PBM were taken from published meta-analyses. Data on 882 cardiovascular operations performed during 2020-2022 were taken from the Florence Nightingale Istanbul Hospital. The costs of treating complications were estimated by applying Turkish Social Security Institution prices to a healthcare resource utilization tool for each complication completed by experts. Results Results from the budget impact analysis showed that, by implementing the first pillar of PBM, the department could have avoided 30 complications and saved 4,189,802 TRY. For the second model based on implementing all three pillars of PBM, 29 complications could have been avoided by reducing the number of transfusions, with budget savings of 6,174,434 TRY. Reducing the length of hospital stay could have enabled 137 additional operations in the given period. Conclusion Implementation of PBM in patients undergoing elective cardiovascular surgery in private hospitals could be a budget-saving strategy in Turkey and may provide an opportunity to increase revenue.
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Affiliation(s)
- Mehtap Tatar
- Vitale Health Economics, Policy and Consultancy, London, UK
| | | | - Utku Zeybey
- Demiroğlu Bilim University, Istanbul, Turkey
| | - Salih Şahin
- Demiroğlu Bilim University, Istanbul, Turkey
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23
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Chan V, Shumilak G, Malhotra AK, Lebel DE, Skaggs DL. Can Intra-Operative Cell Salvage Reduce the Rate of Allogeneic Transfusion in Pediatric Spinal Deformity Surgery? Global Spine J 2024:21925682241309287. [PMID: 39690436 DOI: 10.1177/21925682241309287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The objective of this study was to characterize the association between cell-salvage and allogeneic transfusion rate in pediatric patients undergoing posterior arthrodesis for scoliosis. METHODS NSQIP Pediatric database years 2016-2022 was used. Patients under the age of 18 who received posterior arthrodesis with 7 or more surgical levels for spinal deformity correction were included. Rates of cell-salvage and allogeneic transfusion were determined. We assessed the impact of cell-salvage on the rate of allogeneic transfusion using chi-square test and multivariable logistic regression. RESULTS There were 34,241 patients in this study. The rate of allogeneic transfusion was 21.6% (n = 7407). The allogeneic transfusion rates for idiopathic, neuromuscular, and congenital/syndromic scoliosis were 12.3%, 50.8%, and 25.9%, respectively. Cell-salvage was used in 71.1% of patients (n = 24,344). In the multivariable regression analysis, longer operative time (P < .001), non-idiopathic scoliosis (P < .001), hematocrit less than 35 (P < .001), and ≥13 surgical levels (P < .001) were associated with higher odds of allogeneic transfusion. Use of cell-salvage (P < .001), increasing age (P < .001), and increasing patient weight (P < .001) were associated with significantly lower odds of allogeneic transfusion. In a subanalysis, use of cell-salvage was associated with reduced rate of allogeneic transfusion in patients with idiopathic scoliosis. Cell-salvage was not associated with reduced rates of allogeneic transfusion in neuromuscular and congenital/syndromic scoliosis. CONCLUSION This is the largest study investigating the impact of cell-salvage on rate of allogeneic transfusion in pediatric spinal deformity surgery. Use of cell-salvage is associated with reduced allogeneic transfusion rates in idiopathic scoliosis surgery.
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Affiliation(s)
- Vivien Chan
- Cedars Sinai Spine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Geoffrey Shumilak
- Division of Critical Care Medicine, University of Saskatchewan, Saskatoon, Canada
| | | | - David E Lebel
- Department of Neurosurgery, University of Toronto, Toronto, Canada
| | - David L Skaggs
- Cedars Sinai Spine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Yamashita G, Hirao S, Sugaya A, Sakai J, Komiya T. A five-minute drainage assessment prevents reexploration for bleeding. JTCVS OPEN 2024; 22:65-75. [PMID: 39780793 PMCID: PMC11704565 DOI: 10.1016/j.xjon.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/16/2024] [Accepted: 08/05/2024] [Indexed: 01/11/2025]
Abstract
Objective To evaluate the effectiveness of the five-minute drainage assessment (FMDA) in preventing reexploration for bleeding following cardiovascular surgery. Methods This retrospective review included 1280 patients who underwent cardiovascular surgery between January 2017 and August 2021. Patients were divided into control (n = 695) and FMDA (n = 585) groups. The FMDA involved estimating the bleeding volume from 1 drainage tube every 5 minutes during sternal closure. Reexploration rates, postoperative bleeding volumes, and clinical outcomes were compared between the 2 groups. Results The FMDA group had a significantly lower rate of reexploration for bleeding than the control group (2.2% vs 4.3%; P = .038). The median postoperative bleeding volume within 24 hours was significantly lower in the FMDA group compared to controls (630 mL vs 695 mL; P = .009). Multivariable logistic regression analysis demonstrated that the FMDA was independently associated with a reduced risk of reexploration for bleeding (odds ratio, 0.49; 95% confidence interval, 0.25-0.96; P = .037). The FMDA demonstrated good discriminatory ability for identifying patients at risk of reexploration (area under the receiver operating characteristic curve = 0.782), with an optimal cutoff of 21.0 mL. Conclusions Implementation of the FMDA was associated with a significantly lower rate of reexploration for bleeding compared to the control group. The FMDA provides a simple and reproducible approach that can be readily adopted in surgical practice.
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Affiliation(s)
- Go Yamashita
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shingo Hirao
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Atsushi Sugaya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Jiro Sakai
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
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Abdelkarim A, Straus SL, Moghaddam M, Nakhaei P, Clary B, Malas MB. Postoperative outcomes in patients with anemia undergoing carotid revascularization. J Vasc Surg 2024; 80:1746-1754. [PMID: 39179005 DOI: 10.1016/j.jvs.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Preoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia. STUDY DESIGN This is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses. RESULTS Our study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with a decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA. CONCLUSIONS In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS was associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.
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Affiliation(s)
- Ahmed Abdelkarim
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Sabrina L Straus
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Marjan Moghaddam
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Bryan Clary
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA.
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Larsson M, Nozohoor S, Ede J, Herou E, Ragnarsson S, Wierup P, Zindovic I, Sjögren J. Biomarkers of inflammation and coagulation after minimally invasive mitral valve surgery: a prospective comparison to conventional surgery. SCAND CARDIOVASC J 2024; 58:2347293. [PMID: 38832868 DOI: 10.1080/14017431.2024.2347293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/18/2024] [Accepted: 04/20/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVES Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy. DESIGN A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored. RESULTS The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115-146] vs 79 min [65-112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23-69] vs 61[41-139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400-1040], p = 0.04). CONCLUSIONS Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.
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Affiliation(s)
- Mårten Larsson
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Jacob Ede
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Erik Herou
- Section for Pediatric Cardiac Surgery, Department of Pediatrics, Lund University and Childrens Hospital, Skåne University Hospital, Lund, Sweden
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
- Department of Cardiac Surgery, Yale University and Yale University Hospital, New Haven, USA
| | - Per Wierup
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skåne University Hospital, Lund, Sweden
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Abraham D, Leviner DB, Ronai T, Schwartz N, Levi A, Sharoni E. Effect of perioperative erythropoietin on postoperative morbidity and mortality after cardiac surgery: a meta-analysis of randomized controlled trials. Anaesth Crit Care Pain Med 2024; 43:101428. [PMID: 39366655 DOI: 10.1016/j.accpm.2024.101428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 08/02/2024] [Accepted: 08/04/2024] [Indexed: 10/06/2024]
Abstract
OBJECTIVE Cardiac surgery is known to have high rates of perioperative red blood cell (RBC) transfusions which are associated with increased postoperative mortality and morbidity. Perioperative erythropoietin (EPO) has been suggested to lower perioperative RBC transfusions, and the effect on postoperative morbidity or mortality is unknown. METHODS The registered study protocol is available on PROSPERO (CRD42022314538). We searched the Pubmed, EMbase, and Cochrane CENTRAL databases for randomized controlled trials (RCT) of EPO in cardiac surgery. Outcomes were short-term mortality, acute kidney injury (AKI), re-operation, cerebrovascular accident (CVA), perioperative myocardial infarction (MI), infectious complications, and RBC transfusions. RCT studies of perioperative EPO that reported at least one prespecified outcome of interest were included. RESULTS A total of 21 RCT's (n = 2,763 patients) were included. Mortality analysis included 17 studies (EPO 1,272 patients, control 1,235) and showed no significant difference (risk difference (RD) 0.0004, 95%CI: -0.016, 0.009). EPO did not reduce the incidence of AKI (RD -0.006, 95% CI: -0.038, 0.026) and reoperation (RD 0.001, 95% CI: -0.013, 0.015). The incidence of CVA (RD -0.004, 95% CI: -0.015, 0.007) and perioperative MI (RD -0.008, 95% CI: -0.021, 0.005) was similar between the groups. CONCLUSIONS Although EPO had been proven to reduce perioperative RBC transfusions, we did not find that it reduces the incidence of postoperative short-term mortality, AKI, and reoperation. The study results support that perioperative EPO is also safe, with no rise in thrombotic events, including CVA and perioperative MI.
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Affiliation(s)
- Dana Abraham
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel; The Ruth & Baruch Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Dror B Leviner
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel; The Ruth & Baruch Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Tom Ronai
- The Ruth & Baruch Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Naama Schwartz
- Research Authority, Carmel Medical Center, Haifa, Israel; School of Public Health-University of Haifa, Haifa, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Erez Sharoni
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel; The Ruth & Baruch Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Kiviniemi TO, Anttila V, Pälve K, Vesanen M, Lehto J, Malmberg M, Vasankari T, Airaksinen K, Gunn J. Ferric carboxymaltose in reducing blood transfusions and infections after cardiac surgery. JTCVS OPEN 2024; 22:332-344. [PMID: 39780795 PMCID: PMC11704584 DOI: 10.1016/j.xjon.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/07/2024] [Accepted: 09/04/2024] [Indexed: 01/11/2025]
Abstract
Objective Iron supplementation may reduce postoperative anemia, blood transfusions, and infections in patients undergoing surgery. We sought to assess efficacy and safety of prophylactic intravenous iron supplementation in patients without anemia undergoing cardiac surgery. Methods In this investigator-initiated industry-sponsored single-center randomized double-blind parallel group trial, we enrolled patients undergoing coronary bypass, aortic or mitral valve or ascending aortic surgery who fulfilled prespecified iron blood test safety criteria. Patients were randomized to receive either a single intravenous 1000 mg dose of ferric carboxymaltose (FCM) or placebo (saline only). Independent unblinded study nurse administered the infusion with masked lines and cannula 2 to 21 days before surgery. Primary efficacy end point was a composite of in-hospital blood transfusions >2 U and nosocomial infection. The trial was registered in Eudract (2017-004901-41). Results Altogether 171 patients were screened and 78 randomly assigned to FCM (n = 39) or placebo (n = 39). Trial was prematurely discontinued for futility with regard to reaching the primary end point by the recommendation of the independent data monitoring committee. The primary end point occurred in 3 (7.7%) versus 3 (7.7%) (P = 1.00) of patients assigned to FCM and placebo, respectively, with no difference in blood transfusions >2 U. Fewer hospital readmissions by 3 months follow-up (1 [2.6%] vs 8 [20.5%]; P = .028) were noted in FCM group in a post hoc analysis. Ferritin levels were higher in the FCM group at 3 months indicating more preserved iron stores. Conclusions Prophylactic treatment with FCM was safe but did not reduce the need for blood transfusions or postoperative infections at index hospitalization in patients without anemia undergoing cardiac surgery.
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Affiliation(s)
- Tuomas O. Kiviniemi
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Vesa Anttila
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Kristiina Pälve
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Marko Vesanen
- Department of Clinical Medicine, University of Turku, Turku, Finland
- Medicine, Turku University Hospital, Turku, Finland
| | - Joonas Lehto
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Markus Malmberg
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | | | - K.E.Juhani Airaksinen
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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Wang Y, Yang H, Du K, Liu X, Xiong J, Yu X, Wu Z, Guo Y, Du L. Huaxi integrated blood management reduces the red blood cell transfusion for on-pump cardiac surgery: A quasi-experimental study. J Clin Anesth 2024; 98:111593. [PMID: 39191082 DOI: 10.1016/j.jclinane.2024.111593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/16/2024] [Accepted: 08/20/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVE As many as half of patients undergoing on-pump cardiac surgery require red blood cell transfusion, emphasizing the need for effective strategies that can reduce this need. We conducted this analysis to assess the effectiveness of Huaxi Integrated Blood Management strategy at our medical center. DESIGN Before and after study. PARTICIPANTS Patients who underwent on-pump cardiac surgery were included from January 2019 to December 2021. Two cohorts were compared, one before implementation of the strategy (1 January 2019 until 31 May 2020) and one after implementation (1 June 2020 until 31 December 2021). MEASUREMENTS We evaluated temporal trends in blood transfusion, safety, and efficacy of this strategy. Primary outcomes were the incidence and volume of intra- and postoperative blood transfusions of packed red blood cells. Secondary outcomes are intraoperative and postoperative transfusion of other blood products, all-cause mortality during hospitalization, and incidence of new-onset complications. MAIN RESULTS Our results demonstrated that this integrated strategy effectively decreased both the perioperative packed red blood cell transfusion volume and incidence for patients who underwent the on-pump cardiac surgery. Following the implementation, the incidence of packed red blood cell transfusions decreased by 8.1% during the intraoperative period and by 12.3% during the postoperative period. The mean volume of such transfusions decreased by 0.28 units during the intraoperative period and by 0.49 units during the postoperative period. Hemoglobin concentrations were significantly higher after implementation, and the maximal mean increase was 4.72 g/l on postoperative day 1. Similar benefit of the strategy was observed across subgroups of patients who underwent different types of surgery. CONCLUSIONS The Huaxi Integrated Blood Management strategy may be effective at reducing the need for packed red blood cell transfusion and enhancing patient care.
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Affiliation(s)
- Yishun Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Hao Yang
- Information Centre, West China Hospital, Sichuan University, Sichuan 610041, PR China
| | - Kang Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Xiali Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jiyue Xiong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Xiang Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Lei Du
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China.
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Yamada M, Nakao M, Yamada N, Nakamura H, Itoh M, Yunoki J, Kamohara K, Kimura S, Sueoka E. Immune cell kinetics after allogeneic red blood cell transfusion in patients undergoing cardiovascular surgery. Transfus Clin Biol 2024; 31:223-228. [PMID: 39326780 DOI: 10.1016/j.tracli.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 09/11/2024] [Accepted: 09/19/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND AND OBJECTIVES Recent reports have highlighted that allogeneic blood transfusions decrease immune responses and affect patient outcomes. However, the effects of allogeneic red blood cell transfusions on the composition of immune cells are unclear. We aimed to clarify the alterations in host immune cells in patients who received allogeneic red blood cell transfusions during the perioperative period of cardiovascular surgery. MATERIALS AND METHODS Eight non-transfused, 22 intraoperative autotransfusions, and 36 allogeneic red blood cell-transfused patients undergoing surgery were grouped, and lymphocyte subsets were analyzed using flow cytometry. Blood samples collected before surgery, approximately 1-week, and 1-month after surgery were used for analysis. Surgical parameters, operation time, blood loss, and length of hospital stay were also assessed. RESULTS The group receiving transfusions showed statistical significance compared to non-transfused in the above-mentioned surgical parameters. When comparing the autologous and allogeneic transfusion groups, only the allogeneic red blood transfusion group had a longer hospital stay. In comparing preoperative and 1-week and 1-month postoperative samples, there were almost no differences in CD4, CD20, or NK counts between the autotransfusions and the allogenic red blood cell transfusion groups. In contrast, a significant decrease in lymphocyte count was observed in the allogenic red blood cell transfused group 1-week postoperatively compared to preoperatively. Moreover, the number of CD8 + cells was statistically lowest in the allogeneic transfusion group 1 week after the operation. CONCLUSION Our results suggest that allogeneic red blood cell transfusion could alter immune cell composition especially CD8 + cells, potentially impacting immune function.
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Affiliation(s)
- Marie Yamada
- Department of Transfusion Medicine, Saga University Hospital, Japan
| | - Mami Nakao
- Department of Transfusion Medicine, Saga University Hospital, Japan
| | - Naotomo Yamada
- Department of Transfusion Medicine, Saga University Hospital, Japan
| | - Hideaki Nakamura
- Department of Transfusion Medicine, Saga University Hospital, Japan.
| | - Manabu Itoh
- Department of Thoracic and Cardiovascular Surgery, Japan
| | - Junji Yunoki
- Department of Thoracic and Cardiovascular Surgery, Japan
| | - Keiji Kamohara
- Department of Thoracic and Cardiovascular Surgery, Japan
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Japan
| | - Eisaburo Sueoka
- Department of Clinical Laboratory Medicine, Faculty of Medicine, Saga University, Japan
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Charbonneau H, Savy S, Savy N, Pasquié M, Mayeur N, Angles O, Balech V, Berthelot AL, Croute-Bayle M, Decramer I, Duterque D, Julien V, Mallet L, M'rini M, Quedreux JF, Richard B, Sidobre L, Taillefer L, Thibaud A, Abouliatim I, Berthoumieu P, Garcia O, Soula P, Vahdat O, Breil C, Brunel P, Sciacca G. Comprehensive perioperative blood management in patients undergoing elective bypass cardiac surgery: Benefit effect of health care education and systematic correction of iron deficiency and anemia on red blood cell transfusion. J Clin Anesth 2024; 98:111560. [PMID: 39146724 DOI: 10.1016/j.jclinane.2024.111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/09/2024] [Accepted: 07/17/2024] [Indexed: 08/17/2024]
Abstract
STUDY OBJECTIVE The aim of this study was to investigate the efficacy of a two-step patient blood management (PBM) program in red blood cell (RBC) transfusion requirements among patients undergoing elective cardiopulmonary bypass (CPB) surgery. DESIGN Prospective, non-randomized, two-step protocol design. SETTING Cardiac surgery department of Clinique Pasteur, Toulouse, France. PATIENTS 897 patients undergoing for elective CPB surgery. INTERVENTIONS We conducted a two-steps protocol: PBMe and PBMc. PBMe involved a short quality improvement program for health care workers, while PBMc introduced a systematic approach to pre- and postoperative correction of deficiencies, incorporating iron injections, oral vitamins, and erythropoiesis-stimulating agents. MEASUREMENTS The PBM program's effectiveness was evaluated through comparison with a pre-PBM retrospective cohort after propensity score matching. The primary objective was the proportion of patients requiring RBC transfusions during their hospital stay. Secondary objectives were also analyzed. MAIN RESULTS After matching, 343 patients were included in each group. Primary outcomes were observed in 35.7% (pre-PBM), 26.7% (PBMe), and 21.1% (PBMc) of patients, resulting in a significant reduction (40.6%) in the overall RBC transfusion rate. Both the PBMe and PBMc groups exhibited significantly lower risks of RBC transfusion compared to the pre-PBM group, with adjusted odds ratios of 0.59 [95% CI 0.44-0.79] and 0.44 [95% CI 0.32-0.60], respectively. Secondary endpoints included reductions in transfusions exceeding 2 units, total RBC units transfused, administration of allogeneic blood products, and total bleeding volume recorded on Day 1. There were no significant differences noted in mortality rates or the duration of hospital stays. CONCLUSIONS This study suggests that health care education and systematic deficiency correction are associated with reduced RBC transfusion rates in elective CPB surgery. However, further randomized, controlled studies are needed to validate these findings and refine their clinical application.
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Affiliation(s)
- Hélène Charbonneau
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Stéphanie Savy
- Clinical Research Committee, Clinique Pasteur, Toulouse, France.
| | - Nicolas Savy
- Toulouse Institute of Mathematics, UMR5219 - University of Toulouse; CNRS - UPS IMT, Toulouse, France.
| | - Marie Pasquié
- Clinical Research Committee, Clinique Pasteur, Toulouse, France.
| | - Nicolas Mayeur
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Olivier Angles
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Vincent Balech
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Anne-Laure Berthelot
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Madeleine Croute-Bayle
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Isabelle Decramer
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - David Duterque
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Valerie Julien
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Laurent Mallet
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Mimoun M'rini
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Jean-François Quedreux
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Benoit Richard
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Laurent Sidobre
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Laurence Taillefer
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Adrien Thibaud
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Issam Abouliatim
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Pierre Berthoumieu
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Olivier Garcia
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Philippe Soula
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Olivier Vahdat
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Claude Breil
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Pierre Brunel
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Giovanni Sciacca
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
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Taghizadeh-Waghefi A, Petrov A, Arzt S, Alexiou K, Matschke K, Kappert U, Wilbring M. Minimally Invasive Aortic Valve Replacement for High-Risk Populations: Transaxillary Access Enhances Survival in Patients with Obesity. J Clin Med 2024; 13:6529. [PMID: 39518667 PMCID: PMC11546103 DOI: 10.3390/jcm13216529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 10/15/2024] [Accepted: 10/28/2024] [Indexed: 11/16/2024] Open
Abstract
Background/Objectives: Minimally invasive cardiac surgery is often avoided in patients with obesity due to exposure and surgical access concerns. Nonetheless, these patients have elevated periprocedural risks. Minimally invasive transaxillary aortic valve surgery offers a sternum-sparing "nearly no visible scar" alternative to the traditional full sternotomy. This study evaluated the clinical outcomes of patients with obesity compared to a propensity score-matched full sternotomy cohort. Methods: This retrospective cohort study included 1086 patients with obesity (body mass index [BMI] of >30 kg/m2) undergoing isolated aortic valve replacement from 2014 to 2023. Two hundred consecutive patients who received transaxillary minimally invasive cardiac lateral surgery (MICLAT-S) served as a treatment group, while a control group was generated via 1:1 propensity score matching from 886 patients who underwent full sternotomy. The final sample comprised 400 patients in both groups. Outcomes included major adverse cardio-cerebral events, mortality, and postoperative complications. Results: After matching, the clinical baselines were comparable. The mean BMI was 34.4 ± 4.0 kg/m2 (median: 33.9, range: 31.0-64.0). Despite the significantly longer skin-to-skin time (135.0 ± 37.7 vs. 119.0 ± 33.8 min; p ≤ 0.001), cardiopulmonary bypass time (69.1 ± 19.1 vs. 56.1 ± 21.4 min; p ≤ 0.001), and aortic cross-clamp time (44.0 ± 13.4 vs. 41.9 ± 13.3 min; p = 0.044), the MICLAT-S group showed a shorter hospital stay (9.71 ± 6.19 vs. 12.4 ± 7.13 days; p ≤ 0.001), lower transfusion requirements (0.54 ± 1.67 vs. 5.17 ± 9.38 units; p ≤ 0.001), reduced postoperative wound healing issues (5.0% vs. 12.0%; p = 0.012), and a lower 30-day mortality rate (1.5% vs. 6.0%; p = 0.031). Conclusions: MICLAT-S is safe and effective. Compared to traditional sternotomy in patients with obesity, MICLAT-S improves survival, reduces postoperative morbidity, and shortens hospital stays.
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Affiliation(s)
- Ali Taghizadeh-Waghefi
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Asen Petrov
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Sebastian Arzt
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Konstantin Alexiou
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Klaus Matschke
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Utz Kappert
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
| | - Manuel Wilbring
- Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
- Center for Minimally Invasive Cardiac Surgery, University Heart Center Dresden, 01307 Dresden, Germany
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Vieira ADC, Arnoni RT, Barbosa ABS, Berriel AS, Vianna RG, Issa M. Predictive Factors for Bleeding Risk in Patients Undergoing Valvular Surgery. Arq Bras Cardiol 2024; 121:e20230453. [PMID: 39442138 PMCID: PMC11634210 DOI: 10.36660/abc.20230453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 05/11/2024] [Accepted: 06/12/2024] [Indexed: 10/25/2024] Open
Abstract
BACKGROUND The postoperative period of heart valve surgery is challenging due to the risk of bleeding, leading to complications and increased morbidity and mortality. OBJECTIVE To develop a risk score to predict bleeding in patients after valve surgery. METHODS Retrospective study of patients operated on between 2021 and 2022. Patients with major bleeding were selected based on the BARC and Bojar criteria. A logistic regression analysis was performed for factors related to bleeding and a nomogram of scores was created. For statistical significance, p<0.05 and a 95% confidence interval were considered. The study was approved by the CEP. RESULTS 525 patients were analyzed, with a mean age of 56 years and a predominance of females. The most common valve disease was mitral insufficiency, 8.8% had increased bleeding and 4.3% had surgical reoperations. The variables with statistical significance were tricuspid insufficiency (OR 3.31, p < 0.001), chronic kidney disease/acute kidney injury (OR 2.97, p = 0.006), preoperative hemoglobin (OR 0.73, p < 0.001), reoperations (OR 2, 5, p = 0.003), cardiopulmonary bypass (CPB) time (OR 1.12, p < 0.001), 2-valve approach OR of 2.23 (p = 0.013), use of packed red blood cells OR of 2.8 (p = 0.001). In the multiple model, tricuspid insufficiency, CPB time and preoperative hemoglobin reached statistical significance. CONCLUSION CPB time, preoperative hemoglobin and tricuspid insufficiency were independently associated with postoperative bleeding. The proposed scale is plausible and can help predict the risk of bleeding.
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Affiliation(s)
- Alef de Carvalho Vieira
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Renato Tambellini Arnoni
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
- Hospital Edmundo VasconcelosSão PauloSPBrasilHospital Edmundo Vasconcelos, São Paulo, SP – Brasil
| | - Ana Beatriz Silva Barbosa
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Attila Santos Berriel
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Rafael Guimarães Vianna
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Mario Issa
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
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Rogers CA, Mazza G, Maishman R, Thirard R, Evans J, de Jesus S, Beard C, Angelini G, Millar A, Jarad N, Tomkins S, Hillier J, Suleiman M, Ascione R. Low Frequency Ventilation During Cardiopulmonary Bypass to Protect Postoperative Lung Function in Cardiac Valvular Surgery: The PROTECTION Phase II Randomized Trial. J Am Heart Assoc 2024; 13:e035011. [PMID: 39344668 PMCID: PMC11681471 DOI: 10.1161/jaha.124.035011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 08/15/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) triggers pulmonary injury. In this trial we assessed the feasibility, safety, and efficacy of low frequency ventilation (LFV) during CPB in patients undergoing valvular surgery. METHODS AND RESULTS Patients with severe mitral or aortic valve disease were randomized to either LFV or usual care. Primary outcomes included release of generic inflammatory and vascular biomarkers and the lung-specific biomarker sRAGE (soluble receptor for advance glycation end products) up to 24 hours postsurgery. Secondary outcomes included pulmonary function tests and 6-minute walking test up to 8 weeks postdischarge. Sixty-three patients were randomized (33 LFV versus 30 usual care). Mean age was 66.8 years and 30% were female. LFV was associated with changes of sRAGE (soluble receptor for advance glycation end products) levels (geometric mean ratio, 3.05; [95% CI, 1.13-8.24] 10 minutes post CPB, and 1.07 [95% CI, 0.64-1.79], 0.84 [95% CI, 0.55-1.27], 0.67 [95% CI, 0.42-1.07], and 0.62 [95% CI, 0.45-0.85] at 2, 6, 12, and 24 hours post CPB respectively). No changes were observed for any of the generic biomarkers. Respiratory index soon after surgery (mean difference, -0.61 [95% CI, -1.24 to 0.015] 10 minutes post end of CPB), forced expiratory volume after 1 second/forced vital capacity ratio (0.050 [95% CI, 0.007-0.093] at 6 to 8 weeks pos-surgery), Forced vital capacity alone (95% CI, -0.191 L [-0.394 to 0.012]) and 6-minute walking test score at discharge (63.2 m [95% CI, 12.9-113.6]) were better preserved in the LFV group. No other differences were noted. CONCLUSIONS The use of LFV during CPB in patients undergoing valvular surgery was feasible and safe and was associated with changes in sRAGE levels along with better preserved lung function and walking performance. These observations warrant further investigation in larger future studies. REGISTRATION URL: https://www.isrctn.com; Unique Identifier: ISRCTN75795633.
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Affiliation(s)
- Chris A. Rogers
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Graziella Mazza
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Rachel Maishman
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Russell Thirard
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Jonathan Evans
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Samantha de Jesus
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Chloe Beard
- Bristol Trials Centre, Bristol Medical SchoolUniversity of BristolUK
| | - Gianni Angelini
- Faculty of Life and Health Sciences, Bristol Heart InstituteUniversity of BristolUK
| | - Ann Millar
- Respiratory MedicineSouthmead Hospital BristolUK
| | - Nabil Jarad
- Department of Respiratory MedicineUniversity Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Sally Tomkins
- Faculty of Life and Health Sciences, Bristol Heart InstituteUniversity of BristolUK
| | - James Hillier
- Faculty of Life and Health Sciences, Bristol Heart InstituteUniversity of BristolUK
| | - M‐Saadeh Suleiman
- Faculty of Life and Health Sciences, Bristol Heart InstituteUniversity of BristolUK
| | - Raimondo Ascione
- Faculty of Life and Health Sciences, Bristol Heart InstituteUniversity of BristolUK
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Natour AK, Shepard AD, Nypaver TJ, Rteil A, Corcoran P, Tang X, Kabbani L. Impact of Preoperative Anemia on Hospitalization, Death, and Overall Survival in Patients With Peripheral Artery Disease Undergoing Endovascular Therapy: A Retrospective Cohort Study in the United States and Canada. J Endovasc Ther 2024; 31:805-813. [PMID: 36680405 DOI: 10.1177/15266028221149926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Preoperative anemia is associated with adverse outcomes after cardiac and noncardiac surgeries, but outcomes after an endovascular peripheral vascular intervention (PVI) are not well established. We aimed to assess the association of preoperative anemia with 30 day death, hospital length of stay (LOS), and overall (long term) survival in patients undergoing an endovascular PVI for peripheral artery disease. MATERIALS AND METHODS In this retrospective, cohort study in the United States and Canada, we queried the national Vascular Quality Initiative database for all endovascular PVIs performed between 2010 and 2019, and outcomes were correlated with patients' hemoglobin (Hb) levels. Anemia was classified as mild (Hb=10-13 g/dL for men and 10-12 g/dL for women), moderate (Hb=8-9.9 g/dL), and severe (Hb<8 g/dL). RESULTS A total of 79 707 adult patients who met study criteria underwent endovascular PVI. The mean age was 68 years, and 59% of patients were male. Anemia was documented in 38 543 patients (48%) and was mild in 27 435 (71%), moderate in 9783 (25%), and severe in 1325 (4%). The median follow-up duration was 4 years (range, 1.25-5.78 years). On univariate analysis, 30 day mortality, total LOS, and overall survival were significantly associated with the level of preoperative anemia. These associations persisted in the multivariate models. Kaplan-Meier survival analysis demonstrated an association of death with degree of anemia (p<0.001). CONCLUSION The presence and degree of preoperative anemia were independently associated with increased 30 day mortality and LOS and decreased overall survival for patients with peripheral artery disease who had undergone endovascular PVI. CLINICAL IMPACT The findings from this study have many implications for how to approach vascular surgery in patients with variable hemoglobin levels. Our findings will strengthen our ability to conduct accurate preoperative risk stratification for patients undergoing peripheral vascular interventions. This may also mitigate healthcare expenditures if findings are applied in a way that can lower patient length of postoperative stay while also maintaining quality of care and patient safety. Our results will also serve as guidance for clinical trials, and future prospective trials should evaluate the effect of preoperative optimization of hemoglobin as a potentially modifiable risk factor for outcomes.
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Affiliation(s)
| | | | | | - Ali Rteil
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Paul Corcoran
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Xiaoqin Tang
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
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He J, Liu X, Zhou L, Chen C, Liu J, Yan M, Ming Y, Wu Z, Guo Y, Liu J, Du L. Association between perioperative hemoglobin decrease and outcomes of transfusion in patients undergoing on-pump cardiac surgery: An observational study from two Chinese heart centers. Heliyon 2024; 10:e37843. [PMID: 39347435 PMCID: PMC11437932 DOI: 10.1016/j.heliyon.2024.e37843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/31/2024] [Accepted: 09/11/2024] [Indexed: 10/01/2024] Open
Abstract
Background It is unclear how perioperative hemoglobin decrease (ΔHb) influences the balance between risks and benefits of red blood cell transfusion after cardiac surgery. Methods We retrospectively analyzed data on 8186 adults who underwent valve surgery and/or coronary artery bypass grafting under cardiopulmonary bypass at two large cardiology centers. We explored the potential association of ΔHb, defined relative to the preoperative level and postoperative nadir, with a composite outcome of in-hospital mortality, myocardial infarction, stroke, and acute kidney injury using multivariable logistic regression, restricted cubic spline, and piecewise-linear models. Results Among 6316 patients without preoperative anemia, ΔHb ≥ 50 % was associated with an elevated risk of the composite outcome [adjusted odds ratio (aOR) 1.95, 95 % confidence interval (CI) 1.81-2.35]. Among 869 patients without preoperative anemia and with ΔHb ≥ 50 %, postoperative transfusion of no more than four units of red blood cell appeared to decrease the risk of the composite outcome, whereas transfusion of more than six units increased risk. Among 5447 patients without preoperative anemia and with ΔHb < 50 %, postoperative transfusion appeared not to decrease the risk of the composite outcome. Among 1870 patients with preoperative anemia, ΔHb ≥ 30 % significantly increased the risk of the composite outcome (aOR 1.61, 95 % CI 1.23-2.10), and this risk might be moderated by postoperative transfusion of no more than four units of red blood cell, but increased by transfusion of more than six units. Conclusions ΔHb may influence the balance between risks and benefits of red blood cell transfusion after cardiac surgery.
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Affiliation(s)
- Junhui He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xinhao Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Changwei Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Cushing MM, Cohen T, Fitzgerald MM, Rand S, Sinfort A, Chen D, Keltner N, Ong S, Parra P, Benabdessadek D, Jimenez A, Haas T, Lau C, Girardi NI, DeSimone RA. Trial Of Pathogen-reduced Cryoprecipitate vs. Cryoprecipitated AHF to Lower Operative Transfusions (TOP-CLOT): study protocol for a single center, prospective, cluster randomized trial. Trials 2024; 25:625. [PMID: 39334317 PMCID: PMC11430273 DOI: 10.1186/s13063-024-08398-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 08/12/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Intraoperative hemorrhage in cardiac surgery increases risk of morbidity and mortality. Low pre-operative and perioperative levels of fibrinogen, a key clotting factor, are associated with severity of hemorrhage and increased transfusion of blood components. The ability to supplement fibrinogen during hemorrhagic resuscitation is delayed 45-60 min because cryoprecipitated antihemophilic factor (cryo AHF) is stored frozen, due to a short post-thaw shelf life. Pathogen Reduced Cryoprecipitated Fibrinogen Complex (INTERCEPT Fibrinogen Complex, IFC) can be kept thawed, at room temperature, for up to 5 days, making it possible to be immediately available for hemorrhaging patients. This trial will investigate if earlier correction of acquired hypofibrinogenemia with IFC in hemorrhaging cardiac surgery patients reduces the total number of perioperatively transfused allogeneic blood products (red blood cells, plasma, and platelets) as compared to cryo AHF. METHODS This is a single center, prospective, cluster randomized trial with an adaptive design. Acquired hypofibrinogenemia will be assessed by rotational thromboelastometry (ROTEM) and the threshold for cryo AHF/IFC transfusion defined as FIBTEM A10 ≤ 10 mm in bleeding patients. IFC/cryo AHF will be randomized by 1-month blocks. Cardiac surgery patients will be enrolled in the study if they have an eligible procedure and at least one dose of a cryo AHF/IFC product (approximately 2 g fibrinogen) is transfused. Data from the electronic health record, including the blood bank and lab information systems, will be prospectively collected from the health system's data warehouse. DISCUSSION This trial aims to provide evidence of the clinical efficacy of utilizing readily available thawed IFC during acute bleeding in the cardiac surgery setting compared to traditional cryo AHF. TRIAL REGISTRATION ClinicalTrials.gov NCT05711524. Feb 3, 2023.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA.
| | - Tobias Cohen
- Department of Pathology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Meghann M Fitzgerald
- Department of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Sophie Rand
- Department of Pathology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Abraham Sinfort
- Department of Pathology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Dennis Chen
- Transfusion Medicine Department, NewYork-Presbyterian Hospital/Weill Cornell Medicine Center, New York, NY, USA
| | - Nadia Keltner
- Cerus Corporation, 1220 Concord Ave Suite 600, Concord, CA, USA
| | - Sidney Ong
- Transfusion Medicine Department, NewYork-Presbyterian Hospital/Weill Cornell Medicine Center, New York, NY, USA
| | - Priscilla Parra
- Transfusion Medicine Department, NewYork-Presbyterian Hospital/Weill Cornell Medicine Center, New York, NY, USA
| | - Denden Benabdessadek
- Transfusion Medicine Department, NewYork-Presbyterian Hospital/Weill Cornell Medicine Center, New York, NY, USA
| | - Alexandra Jimenez
- Department of Pathology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Thorsten Haas
- Department of Anesthesiology, University of Florida School of Medicine, 1600 SW Archer Rd, Gainesville, FL, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Natalia Ivascu Girardi
- Department of Anesthesiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Robert A DeSimone
- Department of Pathology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
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Park JH, Siddiqui N, Hrebec WK, Szymanski TJ, Uribe-Marquez S, Miletic KG, Krishnan S. Management of Anticoagulation and Antifibrinolytics in Catastrophic Antiphospholipid Syndrome. Semin Cardiothorac Vasc Anesth 2024; 28:181-187. [PMID: 38705843 DOI: 10.1177/10892532241249782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder that presents with hypercoagulability and results in a lab artifact of prolonged PTT. The most severe form is catastrophic antiphospholipid antibody syndrome (CAPS), which manifests as rapidly progressing thromboses in multiple organ systems leading to multi-organ ischemia. The mainstay management CAPS is anticoagulation and systemic corticosteroids. Antifibrinolytic agents have previously been thought to be relatively contraindicated in CAPS due to the pro-thrombotic nature of the disease; the complex coagulation profile of CAPS can make it difficult to assess the risks and benefits of antifibrinolytic therapy. Also, should a patient with CAPS require cardiopulmonary bypass (CPB) for surgery, it poses a unique challenge in providing appropriate anticoagulation in the setting of prolonged ACT. We present a case of a 32-year-old postpartum female with CAPS requiring heart transplant who safely received intraoperative antifibrinolytic therapy and was successfully anticoagulated during CPB after perioperative plasmapheresis.
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Affiliation(s)
- Jee Ha Park
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nazia Siddiqui
- Department of Anesthesiology, Trinity Health Oakland Hospital, Pontiac, MI, USA
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
| | - William K Hrebec
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | | | | | - Kyle G Miletic
- Department of Cardiothoracic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Sandeep Krishnan
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Anesthesiology, Trinity Health Oakland Hospital, Pontiac, MI, USA
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Hamiko M, Gerdes L, Silaschi M, Seidel H, Westhofen P, Kruppenbacher J, Hertfelder HJ, Oldenburg J, Bakhtiary F, Velten M, Oezkur M, Duerr GD. Investigation of von Willebrand factor multimer abnormalities before and after aortic valve replacement using the Hydragel-5 assay. Thromb Res 2024; 241:109094. [PMID: 38991494 DOI: 10.1016/j.thromres.2024.109094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/24/2024] [Accepted: 07/05/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Severe aortic stenosis (sAS) is associated with acquired von Willebrand syndrome (AVWS) by loss of high-molecular-weight multimers (HMWM) of von Willebrand factor (VWF), potentially resulting in perioperative bleeding. Analysis of VWF multimers remains challenging. Recently, the new, rapid Hydragel 5 assay has been developed, using electrophoretic protein separation for dividing VWF-multimers into low (LMWM), intermediate (IMWM), and HMWM, the hemostatically active part of VWF. Here, we evaluated its impact on predicting blood loss in presence of AVWS after surgical aortic valve replacement (SAVR). METHODS We prospectively examined 52 patients (age: 68 ± 7 years; 54 % male) admitted to SAVR. They were divided in two groups (A: normal VWF, n = 28; B: abnormal VWF, n = 24, defined as VWF-activity/antigen (VWF:Ac/Ag)-ratio < 0.7 and/or HMWM loss). Blood samples and echocardiographic data were collected before, seven days and three months after SAVR. Blood loss and transfusions were recorded. RESULTS Baseline characteristics and clinical data were similar in both groups. HMWM loss was present in 38.5 % of all patients. HMWM, the VWF:Ac/Ag- and HMWM/(IMWM+LMWM)-ratios were significantly decreased preoperatively in group B but normalized after SAVR. Bleeding, re-thoracotomy and transfusion rates were comparable. HMWM loss was inversely correlated with the peak aortic gradient (Pmax) and positively with the aortic valve area (AVA), while HMWM/(IMWM+LMWM)-ratio negatively correlated with the mean aortic gradient (Pmean). CONCLUSION HMWM and HMWM/(IMWM+LMWM)-ratio inversely correlate with severity of AS and normalize after SAVR. The Hydragel-5 assay's might be valuable for routine diagnostics to assess bleeding risk and postoperative normalization of AS and VWF abnormalities in SAVR patients.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Lena Gerdes
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Holger Seidel
- Center for Bleeding Disorders and Transfusion Medicine, (CBT), Bonn, Germany
| | - Philipp Westhofen
- Center for Bleeding Disorders and Transfusion Medicine, (CBT), Bonn, Germany
| | | | - Hans-Joerg Hertfelder
- Center for Bleeding Disorders and Transfusion Medicine, (CBT), Bonn, Germany; Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Markus Velten
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
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Malhotra A, Islam MA, Tavilla G, Williams NE, d'Amato T. Autologous cell salvage in off-pump coronary artery bypass surgery reduces post-operative complications: a retrospective weighted-matching analysis. Gen Thorac Cardiovasc Surg 2024; 72:585-592. [PMID: 38502459 DOI: 10.1007/s11748-024-02012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/24/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Blood transfusion plays a crucial role in coronary artery bypass grafting (CABG). The choice between autologous cell saver (CS) and allogenic blood transfusion (ABT) has been a continuous debate in the medical community, especially within cardiac surgery. This study aimed to assess the outcomes of off-pump CABG (OPCAB) surgery in patients receiving blood solely via cell salvage compared to those receiving ABT or a combination of ABT and CS perioperatively. METHODS A total of 414 patients who underwent isolated OPCAB surgery at our cardiovascular clinic were analyzed. Among them, 250 patients (60.4%) received blood via CS alone, while 164 patients (39.6%) received either ABT or a mix of ABT and CS. Stabilized inverse probability treatment weighted (IPTW) matching technique ensured balance in baseline covariates. RESULTS We found no significant differences in 30-day mortality rates between the CS and ABT groups. The CS group displayed significantly lower rates of overall complications, encompassing stroke, acute kidney injury, atrial fibrillation, and pulmonary complications. Rates of sepsis, readmission, gastrointestinal complications, heparin-induced thrombosis, and deep venous thrombosis were comparable between the two groups. However, in contrast to the ABT group, the CS group exhibited significantly shorter median lengths of hospital stay (LOHS), ICU stay, and ventilation time, along with higher rates of discharge to home rather than acute care facilities. CONCLUSION Our data suggest that autologous blood transfusion via CS results in fewer perioperative complications and faster recovery following OPCAB procedures as compared to ABT.
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Affiliation(s)
- Amber Malhotra
- Department of Cardiovascular Surgery, Baylor Scott & White Medical Center-Temple, Temple, TX, USA
| | - Md Anamul Islam
- Department of Cardiovascular Surgery, Baylor Scott & White Medical Center-Temple, Temple, TX, USA.
| | - Giuseppe Tavilla
- Department of Cardiovascular Surgery, Baylor Scott & White Medical Center-Temple, Temple, TX, USA
| | - Nikki E Williams
- Department of Cardiovascular Surgery, Baylor Scott & White Medical Center-Temple, Temple, TX, USA
| | - Thomas d'Amato
- Department of Cardiovascular Surgery, Baylor Scott & White Medical Center-Temple, Temple, TX, USA
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Horwood CGA, Patel ND, Walker JD, Evans CR. Nonanemic Iron Deficiency in Cardiac Surgery: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2024; 38:1899-1906. [PMID: 38942683 DOI: 10.1053/j.jvca.2024.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVES Anemia and iron deficiency in patients having cardiac surgery increases their perioperative risk. Nonanemic iron deficiency (NAID) in this group is less well-described. We aimed to investigate the incidence and outcomes of patients with NAID undergoing cardiac surgery. DESIGN Retrospective observational study. SETTING A single, tertiary referral center. PARTICIPANTS Adult patients who were preassessed and underwent cardiac surgery during the study period had data collected. We enrolled 537 patients enrolled and divided them into 4 groups according to hemoglobin and ferritin: NAID, nonanemic iron replete, iron-deficiency anemia (IDA), and non-iron-deficiency anemia. INTERVENTIONS This study was not interventional, but assessed the impact of anemia and iron deficiency on patient outcomes. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of NAID. Secondary outcomes included the number of patients who became anemic awaiting surgery, allogeneic transfusion burden, length of stay, postoperative complications, and death. 179 of 537 patients (33.3%) had NAID. Seventeen patients (9.5%) became anemic in the NAID group compared with 7 (3.3%) in the nonanemic iron replete group while awaiting for surgery (p = 0.02). Patients with NAID were more likely to receive allogeneic transfusions (33% vs 23%; p = 0.04) and had poorer recovery of hemoglobin at follow-up (13.2 ± 1.46 g/dL vs 13.9 ± 1.46 g/dL; p < 0.001). CONCLUSIONS NAID is common and can lead to progression to anemia and increased transfusion. Iron replacement should be considered in patients with NAID in the preoperative setting. A prospective interventional trial is required to demonstrate the benefit of being iron replete.
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Affiliation(s)
- Charles G A Horwood
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK.
| | - Nirav D Patel
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Jason D Walker
- Ysbyty Gwynedd, Betsi Cadwalader University Health Board, Bangor, Wales, UK
| | - Caroline R Evans
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
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Kırali K, Aksüt M, Altaş Ö, Gürcü ME, Aydın S. First worldwide use of the hybrid system for extracorporeal circulation in heart transplant. J Cardiothorac Surg 2024; 19:495. [PMID: 39192346 PMCID: PMC11351644 DOI: 10.1186/s13019-024-03010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 08/13/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND This case report documents the first worldwide use of the Hybrid System from Spectrum Medical in a heart transplant procedure, focusing on its safety and efficacy. Traditional cardiopulmonary bypass systems often use an open reservoir, which increases the blood's exposure to air, thereby heightening the risk of an inflammatory response and gas embolism. In contrast, the Hybrid System is designed to improve surgical outcomes by significantly reducing the blood-air interface. This system utilizes a dual-chamber cardiotomy-venous reservoir with a collapsible soft bag, effectively minimizing blood contact with air and foreign materials. However, it is important to note that there is currently no evidence supporting the use of this methodology specifically in heart transplants. CASE PRESENTATION A 41-year-old male managed with a left ventricular assist device because of dilated cardiomyopathy underwent a heart transplant using the Hybrid System. The perioperative and postoperative data provided evidence of the system's effectiveness. The selection of this patient was due to the absence of significant comorbidities unrelated to his primary cardiac condition, making him an ideal candidate to evaluate the system's performance. CONCLUSION The Hybrid System is safe and efficient. The successful implementation in this case highlights its advantages over traditional cardiopulmonary bypass systems, suggesting a promising future in cardiac surgery. Further studies with routine cardiac surgery patients are required to validate these findings.
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Affiliation(s)
- Kaan Kırali
- Department of Cardiovascular Surgery, Koşuyolu High Specialization Education and Research Hospital, Koşuyolu YİEA Hastanesi, Denizer Caddesi No:2, Cevizli Kavşağı, Kartal, Istanbul, 34865, Türkiye.
| | - Mehmet Aksüt
- Department of Cardiovascular Surgery, Koşuyolu High Specialization Education and Research Hospital, Koşuyolu YİEA Hastanesi, Denizer Caddesi No:2, Cevizli Kavşağı, Kartal, Istanbul, 34865, Türkiye
| | - Özge Altaş
- Department of Cardiovascular Surgery, Koşuyolu High Specialization Education and Research Hospital, Koşuyolu YİEA Hastanesi, Denizer Caddesi No:2, Cevizli Kavşağı, Kartal, Istanbul, 34865, Türkiye
| | - Mustafa Emre Gürcü
- Department of Cardiovascular Surgery, Koşuyolu High Specialization Education and Research Hospital, Koşuyolu YİEA Hastanesi, Denizer Caddesi No:2, Cevizli Kavşağı, Kartal, Istanbul, 34865, Türkiye
- Department of Anesthesia, Koşuyolu High Specialization Education and Research Hospital, Istanbul, Türkiye
| | - Sibel Aydın
- Department of Cardiovascular Surgery, Koşuyolu High Specialization Education and Research Hospital, Koşuyolu YİEA Hastanesi, Denizer Caddesi No:2, Cevizli Kavşağı, Kartal, Istanbul, 34865, Türkiye
- Department of Anesthesia, Koşuyolu High Specialization Education and Research Hospital, Istanbul, Türkiye
- Department of Perfusion, Koşuyolu High Specialization Education and Research Hospital, Istanbul, Türkiye
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Park SY, Kang T, Jeong WK, Song JE. Prevalence, Risk Factors, and Postoperative Infection Rates of Blood Transfusion in Lumbar Spinal Fusion Surgery: A Nationwide Population-Based Study. J Clin Med 2024; 13:4867. [PMID: 39201008 PMCID: PMC11355348 DOI: 10.3390/jcm13164867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/12/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Study Design: Retrospective cohort study. Objectives: Effects of blood loss that requires blood transfusion after lumbar spinal fusion remain an important issue. Blood transfusions are used commonly in cases of significant blood loss in lumbar spinal fusion but are associated with adverse effects. The objective was to assess the rate of blood transfusion and the associated risk after lumbar spinal fusion from 2013 to 2018. Methods: In this nationwide population-based cohort study, the Korean Health Insurance Review and Assessment Service database was reviewed retrospectively from 2013 to 2018. Data were extracted from patients who underwent lumbar spinal fusion without history of lumbar spinal surgery in the preceding year. The primary outcome was the rate of blood transfusion within 1 week of surgery. In addition, the risk factors for blood transfusion and the rate of postoperative infection were evaluated. Results: A total of 188,581 patients underwent lumbar spinal fusion between 2013 and 2018. A significant decline in blood transfusions was observed during the study period (56.38-47.51%). The presence of comorbidities was associated with an increased risk of blood transfusion. Patients who underwent the posterior approach were more likely to receive blood transfusion than patients who underwent the anterior or anterior and posterior approach. Receiving blood transfusion was associated with postoperative infection. Conclusions: In the present study, the prevalence, risk factors, and postoperative infection rates associated with blood transfusion in lumbar spinal fusion were identified. Spine surgeons should consider these risk factors in patients at high risk of blood transfusion.
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Affiliation(s)
- Si Young Park
- Department of Orthopedics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Taewook Kang
- Department of Spine Surgery, Cheil Orthopedic Hospital, Seoul 06075, Republic of Korea
| | - Woong Kyo Jeong
- Department of Orthopedics, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea;
| | - Ji Eun Song
- Department of Biostatistics, Korea University College of Medicine, Seoul 02841, Republic of Korea;
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Nordan T, Lee HH, Chen FY, Couper GS, Kawabori M. The Impact of Pre-Heart Transplantation Blood Transfusion Varies Based on Recipient MELD-XI Score. ASAIO J 2024; 70:682-689. [PMID: 38446870 DOI: 10.1097/mat.0000000000002175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Prior studies reveal adverse effects of transfusion on cardiac surgery, but little is known of transfusion impact on heart transplantation. First-time, single-organ adult heart transplant recipients between January 1, 2010, and December 31, 2020, were included, stratified above or below a model for end-stage liver disease excluding international normalized ratio (MELD-XI) score of 9.4, and propensity score matched to their nearest neighbor. A 90 day landmark analysis within each cohort was also performed. Unadjusted analysis showed transfusion recipients, MELD-XI ≥9.4, were more likely to experience post-heart transplantation mortality (Hazard Ratio (HR), 1.352 [95% Confidence Interval (CI), 1.239-1.477], p < 0.001), persisting after adjustment for potential confounders (adjusted HR, 1.211 [95% CI, 1.100-1.335], p < 0.001) and after propensity-score matching (HR, 1.174 [95% CI, 1.045-1.319], p = 0.007). Post-transplant length of stay was longer (25.9 vs. 23.2 days, p < 0.001). Post-transplant dialysis was more common (18.7 vs. 15.9%, p = 0.009). There was no survival difference on 90 day landmarked analysis ( p = 0.108). With MELD-XI <9.4, there was slight survival detriment among transfusion recipients on univariable analysis (HR, 1.111 [95% CI, 1.001-1.234], p = 0.049) but not on multivariable analysis (adjusted HR, 1.061 [95% CI, 0.952-1.181], p = 0.285). There was similar survival after propensity-score matching (HR, 1.032 [95% CI, 0.903-1.180], p = 0.642) and on landmark analysis ( p = 0.581). Ultimately, transfusion was associated with worse post-heart transplantation outcomes among recipients with a MELD-XI ≥9.4.
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Affiliation(s)
- Taylor Nordan
- From the Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
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Saour M, Blin C, Zeroual N, Mourad M, Amico M, Gaudard P, Picot MC, Colson PH. Impact of a bundle of care (intravenous iron, erythropoietin and transfusion metabolic adjustment) on post-operative transfusion incidence in cardiac surgery: a single-centre, randomised, open-label, parallel-group controlled pilot trial. THE LANCET REGIONAL HEALTH. EUROPE 2024; 43:100966. [PMID: 39022429 PMCID: PMC11254177 DOI: 10.1016/j.lanepe.2024.100966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 07/20/2024]
Abstract
Background Red blood cell (RBC) transfusions are frequent in patients after cardiac surgery. This study assessed whether a bundle of care including pre-operative and post-operative administration of erythropoietin (EPO) with intravenous iron supplementation, and restrictive transfusion adjusted for ScvO2 could result in reduced postoperative transfusions. Methods In this single-centre, randomised, open-label, parallel-group controlled pilot study, patients undergoing elective cardiac surgery with high risk of transfusion in a University Hospital were enrolled by the investigator and the randomisation procedure using a central internet-based system was made by the clinical research assistant. Since the trial was open-label, no masking was used. Patients were assigned (1:1) to either the STOP group (40,000 IU subcutaneous EPO combined with 20 mg/kg intravenous ferric carboxymaltose if Hb < 13 g/dL the day before surgery or at ICU admission, and RBC transfusion if Hb ≤ 8 g/dL and ScvO2 ≤ 65%, or additional EPO dose if 8 < Hb < 13 g/dL) or to the control group (RBC transfusion if Hb ≤ 8 g/dL, or, if 8 < Hb < 13 g/dL, intravenous iron sucrose 200 mg or 300 mg according to weight). Primary outcome was the incidence of postoperative RBC transfusion up to hospital discharge or postoperative day 28. The trial is registered with ClinicalTrials.gov, NCT04141631. Findings Between Jan 20, 2020, and Sept 6, 2022, among 128 patients enrolled, 123 (male, 54.4%, 67/123) were included in the full analysis set: 62 in the STOP group and 61 in the control group. Nine patients (14.5%, 9/62) in the STOP group required RBC transfusion vs 19 (31.2%, 19/61) in the control group (odds ratio 0.37 [95% CI: 0.15-0.91], p = 0.03). The median length of follow up to transfusion was 2.6 days (1.5; 4.6) and 3.3 (1.6; 4.2) in control and STOP groups respectively (p = 0.61). Interpretation The bundle of care may reduce postoperative RBC transfusion. The findings should be taken with caution due to the unblinded and exploratory nature of the study. Funding University of Montpellier Hospital and Vifor Pharma.
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Affiliation(s)
- Marine Saour
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Cinderella Blin
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Norddine Zeroual
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Marc Mourad
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Maïlis Amico
- Clinical Research and Epidemiology Unit, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Philippe Gaudard
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
- University of Montpellier, CNRS (Scientific Research Centre), INSERM, PhyMedExp, Montpellier, France
| | - Marie-Christine Picot
- Clinical Research and Epidemiology Unit, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Pascal H. Colson
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
- University of Montpellier, CNRS (Scientific Research Centre), INSERM, Functional Genome Unit, Montpellier, France
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Mittleider D, Gibson CM, Dexter D. Outcomes From Mechanical Thrombectomy for Deep Vein Thrombosis: Insights From the PINC AI Healthcare Database. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102149. [PMID: 39166156 PMCID: PMC11330914 DOI: 10.1016/j.jscai.2024.102149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/02/2024] [Accepted: 04/30/2024] [Indexed: 08/22/2024]
Abstract
Background Mechanical thrombectomy (MT) is playing an increasingly important role in treating deep vein thrombosis (DVT). Although degrees of safety and efficacy have been shown in independent studies, there remains a lack of comparative evidence between MT devices. To address this, we aimed to compare demographics, clinical outcomes, and resource metrics of patients receiving MT for DVT with 3 common devices using a real-world database. Methods Patients receiving MT for DVT between January 2018 and March 2022 were identified from the PINC AI Healthcare Database and divided into analysis populations for the AngioJet ZelanteDVT (AJ), the ClotTriever system (CT), and the Indigo system (IN). Rates of in-hospital mortality, resource utilization, and 30-day readmission were compared. Regression modeling was performed to adjust for potential covariates and compare outcomes. Results A total of 4455 MT encounters were identified and met inclusion criteria (AJ, 1753; CT, 1344; IN, 1358). In-hospital mortality ranged from 1.0% (CT) to 2.9% (IN), with modeling predicting significantly higher odds for the AJ (odds ratio [OR], 3.42) and IN (OR, 3.38) groups. Similarly, higher rates of resource utilization were predicted in the AJ and IN groups when compared with the reference group (CT). Average costs ranged from $29,549 (CT: SD, $30,705) to $42,705 (IN: SD, $41,114). Thirty-day readmissions ranged from 10.0% (AJ) to 14.6% (IN), while modeling predicted significantly greater odds for the IN group (OR, 1.47). Conclusions These results suggest that all MT interventions may be unequal in terms of outcomes and resources, with the CT device associated with lower in-hospital mortality and resource burden.
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Kim HJ, Shin HJ, Lee SW, Heo S, Lee SH, Kim JE, Son HS, Jung JS. Improvement of Transfusion Practice in Cardiothoracic Surgery Through Implementing a Patient Blood Management Program. J Chest Surg 2024; 57:390-398. [PMID: 38584377 PMCID: PMC11240097 DOI: 10.5090/jcs.23.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 04/09/2024] Open
Abstract
Background In this study, we examined the impact of a patient blood management (PBM) program on red blood cell (RBC) transfusion practices in cardiothoracic surgery. Methods The PBM program had 3 components: monitoring transfusions through an order communication system checklist, educating the medical team about PBM, and providing feedback to ordering physicians on the appropriateness of transfusion. The retrospective analysis examined changes in the hemoglobin levels triggering transfusion and the proportions of appropriate RBC transfusions before, during, and after PBM implementation. Further analysis was focused on patients undergoing cardiac surgery, with outcomes including 30-day mortality, durations of intensive care unit and hospital stays, and rates of pneumonia, sepsis, and wound complications. Results The study included 2,802 patients admitted for cardiothoracic surgery. After the implementation of PBM, a significant decrease was observed in the hemoglobin threshold for RBC transfusion. This threshold dropped from 8.7 g/dL before PBM to 8.3 g/dL during the PBM education phase and 8.0 g/dL during the PBM feedback period. Additionally, the proportion of appropriate RBC transfusions increased markedly, from 23.9% before PBM to 34.9% and 58.2% during the education and feedback phases, respectively. Among the 381 patients who underwent cardiac surgery, a significant reduction was noted in the length of hospitalization over time (p<0.001). However, other clinical outcomes displayed no significant differences. Conclusion PBM implementation effectively reduced the hemoglobin threshold for RBC transfusion and increased the rate of appropriate transfusion in cardiothoracic surgery. Although transfusion practices improved, clinical outcomes were comparable to those observed before PBM implementation.
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Affiliation(s)
- Hee Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Suk Woo Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seonyeong Heo
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seung Hyong Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ji Eon Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
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Kim S, Song IA, Oh TK. The association of perioperative blood transfusion with survival outcomes after major cancer surgery: a population-based cohort study in South Korea. Surg Today 2024; 54:712-721. [PMID: 38175292 DOI: 10.1007/s00595-023-02783-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/26/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The correlation between perioperative blood transfusions and the prognosis after major cancer surgery remains controversial. We investigated the association between perioperative blood transfusion and survival outcomes following major cancer surgeries and analyzed trends in perioperative blood transfusions. METHODS Data for this population-based cohort study were obtained from the National Health Insurance Service of South Korea. Adult patients who underwent major cancer surgery between January 1, 2016, and December 31, 2020, were included. The primary endpoint was 90-day mortality. RESULTS The final analysis included 253,016 patients, of which 55,094 (21.8%) received perioperative blood transfusions. In the multivariable logistic regression model, select factors, including neoadjuvant/adjuvant chemotherapy, an increased preoperative Charlson Comorbidity Index, moderate or severe liver disease, liver cancer surgery, and small bowel cancer surgery, were associated with an increased likelihood of blood transfusion. In the multivariable Cox regression model, patients who received blood transfusion had a significantly higher risk of 90-day mortality (hazard ratio: 5.68; 95% confidence interval: 5.37, 6.00; P < 0.001) than those who did not. CONCLUSION We identified potential risk factors for perioperative blood transfusions. Blood transfusion is associated with an increased 90-day mortality risk after major cancer surgery.
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Affiliation(s)
- Saeyeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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de Andrade DPG, de Freitas FL, Borgomoni GB, Goncharov M, de Barros e Silva PGM, Nakazone MA, Campagnucci VP, Tiveron MG, Lisboa LA, Dallan LAO, Jatene FB, Mejia OAV. Age, Renal Failure and Transfusion are Risk Predictors of Prolonged Hospital Stay after Coronary Artery Bypass Grafting Surgery. Arq Bras Cardiol 2024; 121:e20230769. [PMID: 38922261 PMCID: PMC12092024 DOI: 10.36660/abc.20230769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/09/2024] [Accepted: 03/13/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Identifying risk factors in cardiovascular surgery assists in predictability, resulting in optimization of outcomes and cost reduction. OBJECTIVE This study aimed to identify preoperative and intraoperative risk predictors for prolonged hospitalization after coronary artery bypass grafting (CABG) surgery in the state of São Paulo, Brazil. METHODS A cross-sectional analysis using data from the REPLICCAR II database, a prospective, consecutive, multicenter registry that included CABG surgeries performed between August 2017 and July 2019. The primary outcome was a prolonged hospital stay (PHS), defined as a postoperative period exceeding 14 days. Univariate and multivariate logistic regression analyses were performed to identify the predictors with significance set at p <0.05. RESULTS The median age was 63 (57-70) years and 26.55% of patients were female. Among the 3703 patients analyzed, 228 (6.16%) had a PHS after CABG, with a median hospital stay of 17 (16-20) days. Predictors of PHS after CABG included age >60 years (OR 2.05; 95% CI 1.43-2.87; p<0.001); renal failure (OR 1.73; 95% CI 1.29-2.32; p <0.001) and intraoperative red blood cell transfusion (OR 1.32; 95% CI 1.07-2.06; p=0.01). CONCLUSION Age >60 years, renal failure, and intraoperative red blood cell transfusion were independent predictors of PHS after CABG. The identification of these variables can help in multiprofessional strategic planning aimed to enhance results and resource utilization in the state of São Paulo.
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Affiliation(s)
- Diego Pereira Gregório de Andrade
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Fabiane Letícia de Freitas
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Gabrielle Barbosa Borgomoni
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Maxim Goncharov
- Instituto de PesquisaHospital do CoraçãoSão PauloSPBrasilHospital do Coração - Instituto de Pesquisa, São Paulo, SP – Brasil
| | | | - Marcelo Arruda Nakazone
- Faculdade de Medicina de São José do Rio PretoSão José do Rio PretoSPBrasilFaculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP – Brasil
| | - Valquiria Pelisser Campagnucci
- Faculdade de Ciências Médicas da Santa Casa de São PauloSão PauloSPBrasilFaculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP – Brasil
| | - Marcos Gradim Tiveron
- Irmandade da Santa Casa de Misericórdia de MaríliaMaríliaSPBrasilIrmandade da Santa Casa de Misericórdia de Marília, Marília, SP – Brasil
| | - Luiz Augusto Lisboa
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Luís Alberto Oliveira Dallan
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Fabio Biscegli Jatene
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Omar Asdrúbal Vilca Mejia
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
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