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Raiten JM. Con: Robotic surgery is not the preferred technique for coronary revascularization. J Cardiothorac Vasc Anesth 2013; 27:806-8. [PMID: 23849527 DOI: 10.1053/j.jvca.2013.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Jesse Michael Raiten
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Trummer G. Blutungsmenge und Gerinnung, Gabe von Blut, Transfusionstrigger. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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53
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Doussau A, Perez P, Puntous M, Calderon J, Jeanne M, Germain C, Rozec B, Rondeau V, Chêne G, Ouattara A, Janvier G. Fresh-frozen plasma transfusion did not reduce 30-day mortality in patients undergoing cardiopulmonary bypass cardiac surgery with excessive bleeding: the PLASMACARD multicenter cohort study. Transfusion 2013; 54:1114-24. [PMID: 24117772 DOI: 10.1111/trf.12422] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During on-pump cardiac surgery, hemorrhagic complications occur frequently. Fresh-frozen plasma (FFP) is widely transfused to provide coagulation factors. Yet, no randomized clinical trial has demonstrated its benefits on mortality. We assessed the relationship between therapeutic transfusion of FFP and 30-day mortality in cardiac surgery patients suffering from excessive bleeding in a prospective cohort study. STUDY DESIGN AND METHODS Adult patients who underwent on-pump cardiac surgery and experienced excessive bleeding during the 48-hour perioperative period were recruited from 15 French centers between February 2004 and January 2006. Patients who received a preventive FFP transfusion were excluded. The association between FFP transfusion and all cause 30-day mortality was estimated using a Cox proportional hazards model, adjusted for confounding. A propensity score (PS) sensitivity analysis was also performed. RESULTS Among 967 patients included in this study, 58.1% received FFP. The median dose was 11.3 mL/kg (interquartile range, 7.6-19.5). The cumulative 30-day mortality rate was 11.3% (95% confidence interval [CI], 9.5-13.5). FFP transfusion was associated with a higher 30-day mortality (hazard ratio [HR], 3.2; 95% CI, 1.7-6.1) in univariate analysis; however, after adjusting for prognostic factors, there was no longer any association (HR, 1.5; 95% CI, 0.8-3.0, p = 0.20). The results of the PS analysis were consistent with the adjusted analysis. CONCLUSION Among on-pump cardiac surgery patients experiencing excessive perioperative bleeding, there is no evidence of a beneficial impact of FFP transfusion on mortality.
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Affiliation(s)
- Adélaïde Doussau
- Pole de Sante Publique et CIC-EC7, Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique, CHU de Bordeaux, Bordeaux, France; CIC-EC7 et Centre INSERM U897-Epidemiologie-Biostatistique, INSERM, Bordeaux, France; ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Université Bordeaux, Bordeaux, France
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Safety and feasibility of transcatheter aortic valve implantation in patients with severe persistent thrombocytopenia. Blood Coagul Fibrinolysis 2013; 24:732-5. [PMID: 23719018 DOI: 10.1097/mbc.0b013e3283626252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Untreated symptomatic high-grade aortic stenosis remains a lethal disease. Therefore, a comprehensive evaluation is necessary to obtain the best individual treatment for each patient. Recently, transcatheter aortic valve implantation (TAVI) was developed as an innovative therapy for high-risk and inoperable patients. Persistent thrombocytopenia is an established risk for conventional open heart surgery, but is not covered by traditional surgical risk scores. The aim of the study was the investigation of safety and feasibility of TAVI in patients with severe thrombocytopenia. Because of the complicated outcome of patients with persistent thrombocytopenia undergoing heart surgery, we considered all patients with high-grade aortic stenosis and a thrombocyte count of less than 100 per nl as surgical high-risk patients. Out of these high-risk surgical patients, six patients with symptomatic high-grade aortic stenosis and severe thrombocytopenia were deemed to be TAVI candidates and underwent TAVI procedures in 2010 and 2011 (transfemoral: n = 4; transapical: n = 2) at the University Hospital of Frankfurt. The outcome of these patients was analyzed prospectively in order to document safety and feasibility of TAVI in such patients. All TAVI procedures were performed successfully with excellent functional results. There was no occurrence of major or minor bleeding complications, acute renal failure or nosocomial infection. One patient died of an ischemic stroke 12 days after the procedure. The five remaining patients were alive at the 12-month follow-up without relevant cardiovascular events and excellent valve performance. TAVI is an effective and well tolerated method to treat patients with chronic persistent thrombocytopenia and symptomatic high-grade aortic stenosis, and therefore a reasonable alternative to conventional heart surgery in such patients. The indication for TAVI in patients with thrombocytopenia and symptomatic high-grade aortic stenosis might be generated independently from conventional scoring systems.
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Ranucci M, Baryshnikova E, Castelvecchio S, Pelissero G. Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thorac Surg 2013; 96:478-85. [PMID: 23673069 DOI: 10.1016/j.athoracsur.2013.03.015] [Citation(s) in RCA: 200] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 03/04/2013] [Accepted: 03/07/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Postoperative bleeding is common after cardiac surgery. Major bleeding (MB) is a determinant of red blood cell (RBC) transfusion, especially in patients with preoperative anemia. Preoperative anemia and RBC transfusions are recognized risk factors for operative mortality. The present study investigates the role of MB as an independent determinant of operative mortality in cardiac surgery. METHODS A single-center retrospective study based on the institutional database of cardiac surgery in the period 2000-2012 was conducted. Sixteen thousand one hundred fifty-four (16,154) consecutive adult patients undergoing cardiac surgery were analyzed. The impact of postoperative bleeding and MB on operative (30 days) mortality was analyzed univariately and after correction for preoperative anemia, RBC transfusions, and other confounders. RESULTS Postoperative bleeding was significantly (p < 0.001) associated with operative mortality, both in univariate and multivariable models. The main complications associated with MB were thromboembolic complications, infections, and surgical reexploration. In a multivariable model, MB remained an independent predictor of operative mortality (odds ratio, 3.45; 95% confidence interval, 2.78 to 4.28). Preoperative anemia and RBC transfusions coexist in the model, acting with a multiplying effect when associated with MB. CONCLUSIONS Major bleeding is per se a risk factor for operative mortality. However, its deleterious effects are strongly enhanced by RBC transfusions and, to a lesser extent, preoperative anemia. Major bleeding is a partially modifiable risk factor, and adequate preemptive and treatment strategies should be applied to limit this event.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic, IRCCS Policlinico San Donato, Milan, Italy.
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Clinical and economic outcomes associated with blood transfusions among elderly Americans following coronary artery bypass graft surgery requiring cardiopulmonary bypass. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12 Suppl 1:s90-9. [PMID: 23399371 DOI: 10.2450/2013.0170-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 11/08/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND Blood transfusion occurring during hospitalisation for heart surgery has been shown to be associated with increased morbidity and mortality and with increased time spent in hospital, use of healthcare services, and costs. The objective of this study was to assess how perioperative blood transfusion among adults 65 years and older who underwent coronary artery bypass graft surgery requiring cardiopulmonary bypass in the United States is associated with immediate and longer term clinical and economic outcomes. MATERIALS AND METHODS Using data from a 5% random sample of Medicare patients who underwent their first (within 2 years) coronary artery bypass graft requiring cardiopulmonary bypass procedure in 2005 or 2006, this study estimated associations (hazard ratios and regression coefficients) between transfusion status (received or not) and complications after surgery, serious adverse events, death, and costs using Cox proportional hazard and generalised linear models adjusting for patients' demographic and clinical characteristics. RESULTS Adjusted hazard ratios were statistically significant (P<0.05) for risks of complications (1.20), serious adverse events (1.58), and death (1.49). There was also a statistically significantly (P≤0.01) and strong relationship between receiving transfused blood and Medicare payments over the subsequent 45 months following discharge ($5,778 per calendar quarter for those receiving transfusion vs $5,197; all costs are measured in 2011 USD). CONCLUSION Blood transfusion during hospitalisation for coronary artery bypass graft requiring cardiopulmonary bypass was significantly associated with increased long-term post-operative morbidity, mortality, and overall healthcare costs. This study contributes to the evidence demonstrating an association between transfusion and adverse clinical and economic outcomes by using a nationally representative longitudinal cost and utilisation database.
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Optimal treatment of ACS patients: Issues and considerations for upstream antiplatelet therapy. Int J Cardiol 2013; 163:19-25. [DOI: 10.1016/j.ijcard.2011.10.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/18/2011] [Indexed: 11/21/2022]
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Riddell REG, Buth KJ, Sullivan JA. The risks associated with aprotinin use: a retrospective study of cardiac cases in Nova Scotia. Can J Anaesth 2012; 60:16-23. [DOI: 10.1007/s12630-012-9806-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 10/05/2012] [Indexed: 11/29/2022] Open
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Ozolina A, Strike E, Jaunalksne I, Krumina A, Bjertnaes LJ, Vanags I. PAI-1 and t-PA/PAI-1 complex potential markers of fibrinolytic bleeding after cardiac surgery employing cardiopulmonary bypass. BMC Anesthesiol 2012; 12:27. [PMID: 23110524 PMCID: PMC3524048 DOI: 10.1186/1471-2253-12-27] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 10/23/2012] [Indexed: 11/12/2022] Open
Abstract
Background Enhanced bleeding remains a serious problem after cardiac surgery, and fibrinolysis is often involved. We speculate that lower plasma concentrations of plasminogen activator inhibitor – 1 (PAI-1) preoperatively and tissue plasminogen activator/PAI-1 (t-PA/PAI-1) complex postoperatively might predispose for enhanced fibrinolysis and increased postoperative bleeding. Methods Totally 88 adult patients (mean age 66 ± 10 years) scheduled for cardiac surgery, were enrolled into a prospective study. Blood samples were collected pre-operatively, on admission to the recovery and at 6 and 24 hours postoperatively. Patients with a surgical bleeding that was diagnosed during reoperation were discarded from the study. The patients were allocated to two groups depending on the 24-hour postoperative chest tube drainage (CTD): Group I > 500ml, Group II ≤ 500ml. Associations between CTD, PAI-1, t-PA/PAI-1 complex and D-dimer were analyzed with SPSS. Results Nine patients were excluded because of surgical bleeding. Of the 79 remaining patients, 38 were allocated to Group I and 41 to Group II. The CTD volumes correlated with the preoperative plasma levels of PAI-1 (r = − 0.3, P = 0.009). Plasma concentrations of preoperative PAI-1 and postoperative t-PA/PAI-1 complex differed significantly between the groups (P < 0.001 and P = 0.012, respectively). Group I displayed significantly lower plasma concentrations of fibrinogen and higher levels of D-dimer from immediately after the operation and throughout the first 24 hours postoperatively. Conclusions Lower plasma concentrations of PAI-1 preoperatively and t-PA/PAI-1 complex postoperatively leads to higher plasma levels of D-dimer in association with more postoperative bleeding after cardiac surgery.
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Affiliation(s)
- Agnese Ozolina
- Department of Anaesthesiology and Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu street 13, Riga, Latvia.
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Hijazi EM, Musleh GS. Clopidogrel Within Few Hours of Coronary Artery Bypass Grafting Does Significantly Increase the Risk of Bleeding. Cardiol Res 2012; 3:209-213. [PMID: 28348689 PMCID: PMC5358133 DOI: 10.4021/cr226e] [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] [Accepted: 09/27/2012] [Indexed: 11/27/2022] Open
Abstract
Background Postoperative bleeding after coronary artery surgery is partly related to platelet dysfunction. The aim of this study was to evaluate the effects of a single loading dose of clopidogrel (300 mg) before coronary angiography on bleeding and use of blood and blood products after emergency coronary artery bypass surgery (CABG). Methods This is a nonrandomized observational prospective study between January, 2006 till December 2009, at a university hospital, we compare the results of a cohort of 65 patients who received 300 mg clopidogrel during coronary angiography that was followed by emergency CABG (group A or study group) to a cohort of 206 patients who underwent elective coronary artery bypass surgery during the same period by the same surgeons in whom clopidogrel was stopped 7 days before surgery (Group B or control group). Emergency surgery was done because of critical coronary anatomy or because of ongoing chest pain. All patients in the two groups were kept on 100 mg of aspirin until the day of surgery. Outcome data used to compare the two groups, Chest tube drainage in first 12 hours (12 h), need for re-exploration and use of blood and blood product transfusion were prospectively collected. Results Postoperative bleeding, reoperation rates for bleeding and use of blood products are significantly more in those who received a loading dose of clopedogril within few hours of CABG (group A) compared to those who stopped clopedogril for a week before CABG. Conclusions Preoperative 300 mg of clopidogrel is associated with significant increase in post operative bleeding, need for surgical exploration and use of blood and blood product transfusion after CABG.
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Affiliation(s)
- Emad M Hijazi
- Princess Muna AL-Hussein Cardiac Center, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Jordan
| | - Ghassan S Musleh
- Princess Muna AL-Hussein Cardiac Center, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Jordan
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Incidence of sternal wound infection after reexploration in the intensive care unit and the use of local gentamycin. Ann Thorac Surg 2012; 94:2033-7. [PMID: 22959563 DOI: 10.1016/j.athoracsur.2012.07.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 07/16/2012] [Accepted: 07/19/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reoperation for bleeding is a known emergency complication after cardiac operations. When performed in the intensive care unit (ICU), sterility issues arise. Our aim was to examine the incidence of sternal wound infection (SWI) after reexploration in the ICU for bleeding with routine use of local gentamycin. METHODS From January 2003 until December 2009, 4,863 patients underwent cardiac operations through a median sternotomy at our institution. We conducted a retrospective database review identifying all patients who required reoperations. The occurrence of SWI in this group was compared with the general cardiac surgical population. Reoperations for bleeding during this period were conducted routinely in the ICU with prophylactic application of a gentamycin sponge between the sternal halves before closure in all cases. RESULTS Reexploration for bleeding was necessary in 302 patients (6.2%), and SWI occurred in 11, for a rate of 3.6%. SWI occurred in 174 of the 4,561 non-reexplored patients, for a similar rate of 3.8% (p>0.9). These values are similar to our overall rate of SWI of 3.8% (n=185) in the total cohort of 4,863 patients. CONCLUSIONS The incidence of SWI was not increased in our study group after emergency reoperation for bleeding in the ICU after the local use of gentamycin. Our data suggest that reexploration in an ICU setting for bleeding does not pose a sterility challenge and that life-threatening delays due to transfer to the operating theater may be avoided.
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Peña JJ, Mateo E, Martín E, Llagunes J, Carmona P, Blasco L. [Haemorrhage and morbidity associated with the use of tranexamic acid in cardiac surgery: a retrospective, multicentre cohort study]. ACTA ACUST UNITED AC 2012; 60:142-8. [PMID: 22795924 DOI: 10.1016/j.redar.2012.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 05/22/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Postoperative bleeding is common complication, affecting up to 20% of patients, after cardiac bypass surgery. Fibrinolysis is one of the causes of this excessive bleeding, and for this reason the use of tranexamic acid is recommended. The problem with using this is that there are numerous guidelines and differences in the dose to be administered. Our aim was to evaluate whether there were any differences in postoperative bleeding and morbidity after cardiac surgery with the administering of different tranexamic acid doses in three university hospitals. MATERIAL AND METHODS A retrospective, multicentre cohort study was conducted. A total of 146 patients who were subjected to elective cardiac bypass surgery according to the anaesthetic-surgical protocol of each hospital were included in the study. The clinical histories were reviewed, and they were divided into two groups according to the tranexamic acid dose: Group A (high doses), initial dose of 20mg/kg and continuous infusion of 4 mg/kg/hour until closure of the sternotomy. A further 100mg was added to prime the bypass machine. Group B (low doses), initial dose of 10mg/kg followed by a continuous infusion of 2mg/kg/hour until closure of the sternotomy. A further 50mg was added to prime the bypass machine. Variables, such as age, sex, weight, height, type of surgical procedure (valvular, coronary or mixed), haematocrit, INR, and preoperative platelet count, time and temperature of the bypass machine, and haematocrit on sternum closure, were recorded. Among the post-operative variables collected were: debit due to drainage at 6, 12 and 24 hours after surgery, number and type of blood products transfused in the first 24 hours, need for further surgery due to haemorrhage, CVA, TIA, or a new acute myocardial infarction, convulsions, and mortality. RESULTS The incidence of increased bleeding (patients in the 90 percentile) was higher in Group B at all the study evaluation times (P<.05). The incidence of further surgery due to bleeding, and the need for transfusion of ≥ 3 units of packed red cells was lower in Group A (5.56%) than in Group B (13.89%). There were no significant differences in the requirements for blood products transfusions between the groups. As regards associated morbidity, there was one isolated case of convulsion and a perioperative AMI in another case in Group A, and three cases of perioperative AMI in Group B. CONCLUSIONS Elevated doses of tranexamic acid in cardiac bypass surgery appear to significantly reduce bleeding in the first hours after surgery compared to low doses. However, this decrease did not lead to a reduction in the needs for blood products.
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Affiliation(s)
- J J Peña
- Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, España.
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Arnékian V, Camous J, Fattal S, Rézaiguia-Delclaux S, Nottin R, Stéphan F. Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:382-9. [PMID: 22623627 DOI: 10.1093/icvts/ivs224] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Prothrombin complex concentrates (PCCs) are sometimes used as 'off label' for excessive bleeding after cardiopulmonary bypass (CPB). The main objective of this study was to retrospectively evaluate the clinical and biological efficacy of PCC in this setting. METHODS We reviewed the charts of all patients who had undergone cardiac surgery under CPB in our institution for 2 years. Patients treated for active bleeding with haemostatic therapy were identified. Chest tube blood loss was quantified postoperatively in the first 24 h. Coagulation parameters were recorded at intensive care unit admission and in the patient's first 24 h. Thromboembolic complications were also ascertained. RESULTS Seventy-seven patients out of the 677 studied (11.4%) were included: PCC was solely administered in 24 patients (group I), fresh frozen plasma in 26 (group II) and both in 27 (group III). The mean dose of PCC was 10.0 UI/kg ± 3.5 for group I vs 14.1 UI/kg ± 11.2 for group III (P = 0.09). Initial blood loss in the first hour was different between the three groups (P = 0.05): 224 ± 131 ml for group I, 369 ± 296 ml for group II and 434 ± 398 ml for group III. Only group I vs group III presented a significant difference (P = 0.02). Variations of blood loss over time were no different according to the treatment groups (P = 0.12). Reductions in blood loss expressed in percentage showed no difference between the three groups after 2 h: 54.5% (68.6-30.8) for group I; 45.0% (81.6-22.2) for group II; 57.6 (76.0-2.1) for group III; (P = 0.89). Re-exploration for bleeding involved 1 patient in group I (4%), 2 in group II (8%) and 10 in group III (37%) (P = 0.002). Except for fibrinogen, variations of prothrombin time, activated partial thromboplastin time and platelets with time were not different according to the treatment groups. Cerebral infarction occurred in one patient in group II. CONCLUSIONS Administration of low-dose of PCC significantly decreased postoperative bleeding after CPB.
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Affiliation(s)
- Vrigina Arnékian
- Cardiothoracic Intensive Care Unit, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
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Biancari F, Mikkola R, Heikkinen J, Lahtinen J, Airaksinen KEJ, Juvonen T. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2012; 41:50-5. [PMID: 21640602 DOI: 10.1016/j.ejcts.2011.04.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of re-exploration for bleeding after cardiac surgery on the immediate postoperative outcome. METHODS Systematic review of the literature and meta-analysis of data on re-exploration for bleeding after adult cardiac surgery were performed. RESULTS The literature search yielded eight observational studies reporting on 557,923 patients and were included in the present analysis. Patients requiring re-exploration were significantly older, more frequently males, had a higher prevalence of peripheral vascular disease and preoperative exposure to aspirin, and more frequently underwent urgent/emergency surgery. Re-exploration was associated with significantly increased risk ratio (RR) of immediate postoperative mortality (RR 3.27, 95% confidence interval (CI) 2.44-4.37), stroke, need of intra-aortic balloon pump, acute renal failure, sternal wound infection, and prolonged mechanical ventilation. The pooled analysis of four studies (two being propensity score-matched pairs analysis) reporting adjusted risk for mortality led to an RR of 2.56 (95%CI 1.46-4.50). Studies published during the last decade tended to report a higher risk of re-exploration-related mortality (RR 4.30, 95%CI 3.09-5.97) than those published in the 1990s (RR 2.75, 95%CI 2.06-3.66). CONCLUSIONS This study suggests that re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland.
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A phase 2 prospective, randomized, double-blind trial comparing the effects of tranexamic acid with ecallantide on blood loss from high-risk cardiac surgery with cardiopulmonary bypass (CONSERV-2 Trial). J Thorac Cardiovasc Surg 2012; 143:1022-9. [DOI: 10.1016/j.jtcvs.2011.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 03/29/2011] [Accepted: 06/06/2011] [Indexed: 11/19/2022]
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Biancari F, Mikkola R, Heikkinen J, Lahtinen J, Kettunen U, Juvonen T. Individual surgeon's impact on the risk of re-exploration for excessive bleeding after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2012; 26:550-6. [PMID: 22498634 DOI: 10.1053/j.jvca.2012.02.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Excessive bleeding requiring re-exploration is a severe complication that may affect the outcome after coronary artery bypass grafting. The authors hypothesized that surgeon performance may contribute significantly to such a complication. DESIGN Retrospective. SETTING Tertiary referral center in a university hospital. PARTICIPANTS Two thousand one patients. INTERVENTIONS Isolated coronary artery bypass grafting. RESULTS Re-exploration for bleeding was performed in 113 patients (5.3%). Re-exploration was performed ≥3 days after surgery in 11 patients. The surgical site of bleeding was identified in 83 patients (73.5%). Rates of re-exploration for excessive bleeding ranged from 1.4% to 11.7% according to different surgeons (p < 0.0001). When adjusted for the additive European System for Cardiac Operative Risk Evaluation, re-exploration for bleeding was associated with increased risks of low-cardiac-output syndrome (odds ratio [OR] 2.239, 95% confidence interval [CI] 1.328-3.777), prolonged need for inotropes (OR 1.894, 95% CI 1.198-2.994), and an intensive care unit stay ≥5 days (OR 2.129, 95% CI 1.202-3.770). Logistic regression showed that an individual surgeon (p < 0.0001), preoperative body mass index <25 kg/m(2) (OR 2.733, 95% CI 2.145-3.481), and estimated glomerular filtration rate <30 mL/min/1.73 m(2) (OR 3.891, 95% CI 1.669-9.076) were independent predictors of re-exploration for excessive bleeding. An individual surgeon also was an independent predictor of a postoperative blood loss ≥1,600 mL. CONCLUSIONS An individual surgeon has a major impact on postoperative bleeding, and a meticulous surgical technique is expected to decrease significantly such a severe complication.
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Affiliation(s)
- Fausto Biancari
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland.
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67
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Greiff G, Stenseth R, Wahba A, Videm V, Lydersen S, Irgens W, Bjella L, Pleym H. Tranexamic acid reduces blood transfusions in elderly patients undergoing combined aortic valve and coronary artery bypass graft surgery: a randomized controlled trial. J Cardiothorac Vasc Anesth 2012; 26:232-8. [PMID: 21924636 DOI: 10.1053/j.jvca.2011.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effects of tranexamic acid on postoperative blood loss and transfusion requirements in elderly patients undergoing combined aortic valve replacement and coronary artery bypass graft surgery (CABG). DESIGN A prospective, randomized, double-blinded, placebo-controlled, parallel-group trial. SETTING A university hospital (single institution). PARTICIPANTS Sixty-four patients 70 years or older undergoing combined aortic valve replacement and CABG surgery were included. One patient was withdrawn from the study after randomization by the attending surgeon because of a change in the surgical procedure. The remaining 63 patients were analyzed as intention to treat. INTERVENTIONS The included patients were randomized to treatment with either tranexamic acid, 10 mg/kg, as a bolus injection before surgery followed by 1 mg/kg/h as an infusion during surgery, or a corresponding volume of 0.9% sodium chloride. MEASUREMENTS AND MAIN RESULTS Postoperative blood loss was recorded for 16 hours. The transfusion of blood products was recorded during the entire hospital stay. The number of packed red cell transfusions given to the patients was significantly lower in the tranexamic acid group compared with the placebo group (median, 3.0 [interquartile range, 2-5] v 5.0 [3-7], p = 0.049). CONCLUSION Tranexamic acid reduced the number of packed red cell transfusions given to patients 70 years or older undergoing combined aortic valve replacement and CABG surgery.
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Affiliation(s)
- Guri Greiff
- Department of Cardiothoracic Anesthesia and Intensive Care, St Olav University Hospital, Trondheim, Norway.
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Kristensen KL, Rauer LJ, Mortensen PE, Kjeldsen BJ. Reoperation for bleeding in cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 14:709-13. [PMID: 22368106 DOI: 10.1093/icvts/ivs050] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
At Odense University Hospital (OUH), 5-9% of all unselected cardiac surgical patients undergo reoperation due to excessive bleeding. The reoperated patients have an approximately three times greater mortality than non-reoperated. To reduce the rate of reoperations and mortality due to postoperative bleeding, we aim to identify risk factors that predict reoperation. A total of 1452 consecutive patients undergoing cardiac surgery using extracorporeal circulation (ECC) between November 2005 and December 2008 at OUH were analysed. Statistical tests were used to identify risk factors for reoperation. We performed a case-note review on propensity-matched patients to assess the outcome of reoperation for bleeding regarding morbidity and mortality. In total, 101 patients (7.0%) underwent surgical re-exploration due to excessive postoperative bleeding. Significant risk factors for reoperation for bleeding after cardiac surgery was low ejection fraction, high EuroSCORE, procedures other than isolated CABG, elongated time on ECC, low body mass index, diabetes mellitus and preoperatively elevated s-creatinine. Reoperated patients significantly had a greater increase in postoperative s-creatinine and higher mortality. Surviving reoperated patients significantly had a lower EuroSCORE and a shorter time on ECC compared with non-survivors. The average time to re-exploration was 155 min longer for non-survivors when compared with survivors.
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69
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Christensen MC, Dziewior F, Kempel A, von Heymann C. Increased Chest Tube Drainage Is Independently Associated With Adverse Outcome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2012; 26:46-51. [DOI: 10.1053/j.jvca.2011.09.021] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Indexed: 11/11/2022]
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Abstract
Accurate and readily available systems for risk stratification and a wide array of antithrombotic agents, on top of classical anti-ischemic drugs, provide the noninvasive cardiologist admitting the patient in the CCU with an effective and reliable armamentarium for the safe management of most patients with ACS. From the interventionalist's perspective, the immediate knowledge of the coronary anatomy yields the most valuable information to address the most appropriate treatment. The sooner angiography is performed the higher the benefit for patients at moderate to high risk, but if performed by expert teams and with the correct use of modern drugs and devices, the invasive approach has the potential to reduce costs and length of hospital stay also in low-risk patients. Although still some reluctance remains to equalize treatment strategies for patients with STEMI to those with NSTEMI, such differences will likely disappear in the near future with upcoming new evidence. Cardiac surgery may represent a life-saving alternative for patients presenting with NSTEMI evolving in cardiogenic shock or with mechanical complications, or in patients unsuitable for PCI or with failed PCI attempts. In stabilized conditions after the treatment of the culprit lesion, patients with severe multivessel disease may benefit from cardiac surgery to complete myocardial revascularization. Indications for CABG in this setting should be evaluated in the context of a local "heart team" or through prespecified protocols in centers without cardiac surgery on site.
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72
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Alström U, Granath F, Friberg Ö, Ekbom A, Ståhle E. Risk factors for re-exploration due to bleeding after coronary artery bypass grafting. SCAND CARDIOVASC J 2011; 46:39-44. [DOI: 10.3109/14017431.2011.629004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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73
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Efficacy and Safety of Aprotinin in Neonatal Congenital Heart Operations. Ann Thorac Surg 2011; 92:958-63. [DOI: 10.1016/j.athoracsur.2011.04.094] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 04/21/2011] [Accepted: 04/26/2011] [Indexed: 11/18/2022]
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74
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Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, Sabik JF. Morbidity of Bleeding After Cardiac Surgery: Is It Blood Transfusion, Reoperation for Bleeding, or Both? Ann Thorac Surg 2011; 91:1780-90. [DOI: 10.1016/j.athoracsur.2011.03.105] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/16/2022]
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Chapman AJ, Blount AL, Davis AT, Hooker RL. Recombinant factor VIIa (NovoSeven RT) use in high risk cardiac surgery. Eur J Cardiothorac Surg 2011; 40:1314-8; discussion 1318-9. [PMID: 21601468 DOI: 10.1016/j.ejcts.2011.03.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 03/23/2011] [Accepted: 03/28/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The use of recombinant factor VIIa (rFVIIa) (NovoSeven RT(®)) to establish hemostasis during massive perioperative bleeding in cardiac surgery has been explored in several retrospective studies. While early results are promising, a paucity of data leaves many questions about its safety profile. We sought to further define its use and associated outcomes in a large cohort study at a single institution. METHODS A retrospective cohort study design was used, in which 236 patients received rFVIIa for bleeding after cardiac surgery. These patients were matched with a cohort of 213 subjects, who had similar operations during the same period of time. Primary end points included thrombo-embolic events, mortality, incidence of re-operation, use of blood products, and patient disposition at 30 days. Statistical significance was assessed at p < 0.05. RESULTS There was no statistically significant difference in the incidence of stroke (3.4%, 1.9%; p = 0.32), renal failure (8.5%, 7.0%; p = 0.57), or 30-day mortality (7.7%, 4.3%; p = 0.14) between the rFVIIa and the control groups, respectively. The rFVIIa group did experience a higher rate of re-operation for bleeding (11.0%, 1.9%; p = 0.0001) and had a two-fold increase in the use of each of the following: cryoprecipitate, fresh-frozen plasma, platelets, and packed red blood cells, relative to the control group (p < 0.00001). CONCLUSIONS rFVIIa is an effective hemostatic agent for intractable bleeding in high-risk cardiac surgery with an acceptable safety profile. rFVIIa does not appear to be associated with increased postoperative complications, including thrombo-embolic events and death.
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Hacquard M, Durand M, Lecompte T, Boini S, Briançon S, Carteaux JP. Off-label use of recombinant activated factor VII in intractable haemorrhage after cardiovascular surgery: an observational study of practices in 23 French cardiac centres (2005-7). Eur J Cardiothorac Surg 2011; 40:1320-7. [PMID: 21550261 DOI: 10.1016/j.ejcts.2011.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 03/17/2011] [Accepted: 03/21/2011] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The study aimed to describe French off-label use of rFVIIa for intractable bleeding in major cardiovascular surgery. METHODS Retrospective observational analysis of data from 2005 to October 2007 (no formal guidelines were available) was employed. The collect request form was elaborated by a multidisciplinary committee. RESULTS Data on 109 patients--37 mechanical cardiac assist devices--were collected, with repeated injection for 24%. Bleeding stopped, decreased or continued in 43%, 37% and 20% of the cases, respectively. For patients treated in the intensive care unit (ICU), hourly bleeding decreased from 365 ± 212 to 115 ± 106 ml h(-1) (p<0.001). The median number of transfused products was 25 (2-90) before and 6 (0-48) after rFVIIa (p<0.001). Most patients had been well compensated with fibrinogen (>1g.l(-1)) and platelets (>50 G.l(-1)) before rFVIIa. The bleeding outcome (cessation, decrease or no change) was associated with the infused dose (81 ± 31, 71 ± 24, 64 ± 23 μg.kg(-1); p = 0.044) and did not differ whether rFVIIa was administered in the operating room (49%) or ICU (51%). Thrombotic events occurred in 13% of patients without assist devices and in 27% of those with them (but without obvious intra-device clotting). The overall 28-day survival rate was 60% and associated with bleeding outcome (p = 0.002). CONCLUSIONS rFVIIa rescue therapy was followed by control of bleeding in a substantial number of the patients with seemingly acceptable safety; however, thrombotic risk remains a matter of concern. Our observational study suggests that the dose to be tested prospectively is at least 80 μg.kg(-1).
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Administration of recombinant activated factor VII in the intensive care unit after complex cardiovascular surgery: clinical and economic outcomes. J Thorac Cardiovasc Surg 2011; 141:1469-77.e2. [PMID: 21457998 DOI: 10.1016/j.jtcvs.2011.02.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 11/12/2010] [Accepted: 02/25/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Refractory bleeding after complex cardiovascular surgery often leads to increased length of stay, cost, morbidity, and mortality. Recombinant activated factor VII administered in the intensive care unit can reduce bleeding, transfusion, and surgical re-exploration. We retrospectively compared factor VII administration in the intensive care unit with reoperation for refractory bleeding after complex cardiovascular surgery. METHODS From 1501 patients who underwent cardiovascular procedures between December 2003 and September 2007, 415 high-risk patients were identified. From this cohort, 24 patients were divided into 2 groups based on whether they either received factor VII in the intensive care unit (n = 12) or underwent reoperation (n = 12) for refractory bleeding. Preoperative and postoperative data were collected to compare efficacy, safety, and economic outcomes. RESULTS In-hospital survival for both groups was 100%. Factor VII was comparable with reoperation in achieving hemostasis, with both groups demonstrating decreases in chest tube output and need for blood products. Freedom from reoperation was achieved in 75% of patients receiving factor VII, whereas reoperation was effective in achieving hemostasis alone in 83.3% of patients. Prothrombin time, international normalized ratio, and median operating room time were significantly less (P < .05) in patients who received factor VII. Both groups had no statistically significant differences in other efficacy, safety, or economic outcomes. CONCLUSIONS Factor VII administration in the intensive care unit appears comparable with reoperation for refractory bleeding after complex cardiovascular surgical procedures and might represent an alternative to reoperation in selected patients. Future prospective, randomized controlled trials might further define its role.
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Reddy B, Pagel C, Vuylsteke A, Gerrard C, Nashef S, Utley M. An operational research approach to identify cardiac surgery patients at risk of severe post-operative bleeding. Health Care Manag Sci 2011; 14:215-22. [PMID: 21404116 DOI: 10.1007/s10729-011-9152-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
Abstract
Severe post-operative bleeding can lead to adverse outcomes for cardiac surgery patients and is a relatively common complication of cardiac surgery. One of the most effective drugs to prevent such bleeding, aprotinin, has been withdrawn from the market due to concerns over its safety. Alternative prophylactic drugs which can be given to patients to prevent bleeding can result in significant side effects and are expensive. For this reason it is difficult to make a clinical or economic case for administering these drugs to all cardiac surgery patients, and the prevailing view is that their use should be targeted at patients considered to be at relatively high risk of post-operative bleeding. However, there is currently no objective method for identifying such patients. Over the past 7 years, a team of clinicians and researchers at Papworth Hospital has collected data concerning post-operative blood loss for each cardiac surgery patient, totalling 11,592 consecutive records. They approached a team of operational researchers (MU, ACP, BR) with extensive experience of developing clinical risk models with the aim of devising a risk stratification scheme that could potentially be used to identify a cohort of higher risk patients. Such patients could be treated with the available prophylactic drugs or recruited to studies to evaluate new interventions. This paper is intended to describe the Operational Research process adopted in the development of this scheme. A concise description of the scheme and its clinical interpretation is published elsewhere.
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Affiliation(s)
- Brian Reddy
- Clinical Operational Research Unit, University College London, London, UK
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79
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Brown C, Joshi B, Faraday N, Shah A, Yuh D, Rade JJ, Hogue CW. Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics. Anesth Analg 2011; 112:777-99. [PMID: 21385977 DOI: 10.1213/ane.0b013e31820e7e4f] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.
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Affiliation(s)
- Charles Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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80
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Mariscalco G, Bruno VD, Cottini M, Borsani P, Banach M, Piffaretti G, Dominici C, Beghi C, Sala A. Optimal Timing of Discontinuation of Clopidogrel and Risk of Blood Transfusion After Coronary Surgery - Propensity Score Analysis -. Circ J 2011; 75:2805-2812. [DOI: 10.1253/circj.cj-11-0620] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Giovanni Mariscalco
- Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria
| | - Vito Domenico Bruno
- Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria
| | - Marzia Cottini
- Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria
| | - Paolo Borsani
- Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz
| | - Gabriele Piffaretti
- Department of Surgical Sciences, Vascular Surgery Unit, Varese University Hospital, University of Insubria
| | - Carmelo Dominici
- Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria
| | - Cesare Beghi
- Heart Surgery Department, University of Parma Medical School
| | - Andrea Sala
- Department of Surgical Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria
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81
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Smithburger PL, Kane-Gill SL, Seybert AL. Drug-Drug Interactions in Cardiac and Cardiothoracic Intensive Care Units. Drug Saf 2010; 33:879-88. [DOI: 10.2165/11532340-000000000-00000] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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82
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Early antiplatelet therapy in coronary artery bypass grafting: a calculated benefit. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:317-25. [PMID: 22437514 DOI: 10.1097/imi.0b013e3181f63b30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Studies have demonstrated that antagonists of platelet activity, including aspirin and clopidogrel, reduce the risk of major adverse events in patients with acute coronary syndromes. Although antiplatelet agents also convey an increased risk of bleeding, particularly in patients proceeding to coronary artery bypass graft surgery, in most cases, the benefits of early initiation of antiplatelet therapy outweigh the risks. The purpose of this review is to distinguish perceived and actual risk versus the benefit associated with early antiplatelet therapy to help clinicians make informed decisions on using these agents in an acute setting where patients may require coronary artery bypass grafting.
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Trachiotis GD. Early Antiplatelet Therapy in Coronary Artery Bypass Grafting a Calculated Benefit. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010. [DOI: 10.1177/155698451000500502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory D. Trachiotis
- Division of Cardiothoracic Surgery, The George Washington University Medical Center and Veterans Affairs Medical Center, Washington, DC USA
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Jarral OA, Jarral RA, Khan MT, Zakkar M, Punjabi PP. A simple technique to control anastomotic suture line bleeding. Ann Thorac Surg 2010; 90:1030-1. [PMID: 20732549 DOI: 10.1016/j.athoracsur.2009.10.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 10/05/2009] [Accepted: 10/26/2009] [Indexed: 10/19/2022]
Abstract
We present a simple and practical method of eliminating anastomotic suture line bleeding that we believe is a safer method than the traditional approach of taking extra stitches around the suture line.
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Affiliation(s)
- Omar A Jarral
- Division of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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85
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Plasma activity of individual coagulation factors, hemodilution and blood loss after cardiac surgery: A prospective observational study. Thromb Res 2010; 126:e128-33. [DOI: 10.1016/j.thromres.2010.05.028] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 05/11/2010] [Accepted: 05/31/2010] [Indexed: 11/18/2022]
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86
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Mataraci I, Polat A, Toker ME, Tezcan O, Erkin A, Kirali K. Postoperative Revision Surgery for Bleeding in a Tertiary Heart Center. Asian Cardiovasc Thorac Ann 2010; 18:266-71. [DOI: 10.1177/0218492310369030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We analyzed cases of re-exploration for bleeding after 19,680 open heart operations performed between January 1995 and January 2009 to determine the risk factors for mortality and morbidity. Half of the 282 patients reexplored had nonsurgical causes of bleeding. The patients were grouped according to the timing of reoperation, early reexploration being on the day of the operation. Mortality, total morbidity, and the need for transfusion of any blood product were compared between the early and late reexploration groups. Most patients (77.7%) were reexplored early. Overall mortality was 8.5% (24 patients). Mortality, total morbidity, renal, gastrointestinal, neurologic and infectious complications, and low cardiac output differed significantly between the 2 groups. Significant predictors of mortality were old age, female sex, left ventricular dysfunction, noncoronary operations, and delayed reoperation. Predictors of morbidity were old age, preoperative dialysis, tobacco use, chronic lung disease, and delayed reoperation. No factors were found to be associated with the need for transfusion.
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Affiliation(s)
| | - Adil Polat
- Cardiovascular Surgery, JFK Hospital Istanbul, Turkey
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Karthekeyan RB, Babu H, Vakamudi M, Selvaraju K, Srigiri R, Saldanha R. Effects of clopidogrel on perioperative blood loss in off pump elective coronary artery bypass surgery. A prospective single blinded observational study. Indian J Thorac Cardiovasc Surg 2010. [DOI: 10.1007/s12055-009-0031-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Makar M, Taylor J, Zhao M, Farrohi A, Trimming M, D’Attellis N. Perioperative Coagulopathy, Bleeding, and Hemostasis During Cardiac Surgery. ACTA ACUST UNITED AC 2010. [DOI: 10.1177/1944451609357759] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac surgery patients use 10%-25% of the blood products transfused annually in the United States. The transfusion of red blood cells or blood products has been the subject of intense scrutiny over the past 10 years. Bleeding after cardiac surgery can be surgical or nonsurgical and lead to hemodynamic compromise and surgical reexploration. Because hemorrhage and blood product transfusions are associated with multiple negative outcomes, including increased mortality, it is prudent to understand the mechanisms responsible for nonsurgical bleeding. This review focuses on the physiology of the normal coagulation and fibrinolysis, risk factors associated with patients presenting for cardiac surgery, impairments of normal hemostasis associated with cardiac surgery and cardiopulmonary bypass (CPB), and potential interventions to reduce perioperative blood loss and blood transfusion.
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Affiliation(s)
- Moody Makar
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jamie Taylor
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Maxnu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Farrohi
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Trimming
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicola D’Attellis
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
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Szabó G, Veres G, Radovits T, Haider H, Krieger N, Bährle S, Miesel-Gröschel C, Niklisch S, Karck M, van de Locht A. Effects of novel synthetic serine protease inhibitors on postoperative blood loss, coagulation parameters, and vascular relaxation after cardiac surgery. J Thorac Cardiovasc Surg 2010; 139:181-8; discussion 188. [DOI: 10.1016/j.jtcvs.2009.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 08/09/2009] [Accepted: 09/07/2009] [Indexed: 10/20/2022]
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90
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Lessons from the aprotinin saga: current perspective on antifibrinolytic therapy in cardiac surgery. J Anesth 2009; 24:96-106. [DOI: 10.1007/s00540-009-0866-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 06/04/2009] [Indexed: 11/26/2022]
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91
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Sørensen B, Asvaldsdottir HS, Gudmundsdottir BR, Onundarson PT. The combination of recombinant factor VIIa and fibrinogen correct clotting ex vivo in patient samples obtained following cardiopulmonary bypass surgery. Thromb Res 2009; 124:695-700. [DOI: 10.1016/j.thromres.2009.08.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 08/03/2009] [Accepted: 08/04/2009] [Indexed: 10/20/2022]
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Mehta RH, Sheng S, O'Brien SM, Grover FL, Gammie JS, Ferguson TB, Peterson ED. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: incidence, risk factors, time trends, and outcomes. Circ Cardiovasc Qual Outcomes 2009; 2:583-90. [PMID: 20031896 DOI: 10.1161/circoutcomes.109.858811] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Reoperation for bleeding represents an important complication in patients undergoing coronary artery bypass surgery (CABG). Yet, few studies have characterized risk factors and patient outcomes of this event. METHODS AND RESULTS We evaluated 528 686 CABG patients at >800 hospitals in the Society of Thoracic Surgeons National Cardiac Database (2004 to 2007). Clinical features and in-hospital outcomes were evaluated in patients with and without reoperation for bleeding after CABG. Logistic regression was used to identify predictors of risk of this event and to estimate weights for an additive risk score. A total of 12 652 CABG patients (2.4%) required reoperation for bleeding. These rates remained fairly stable over time (2.2%, 2.3%, 2.5%, and 2.4% from 2004 to 2007, respectively). Although overall operative mortality was 4.5-fold higher in patients requiring reoperation for bleeding versus those who did not (2.0% versus 9.1%), this mortality risk declined significantly over time (11.3%, 9.5%, 8.8%, and 8.2% from 2004 to 2007, respectively, P for trend=0.0006). Factors associated with higher risk for reoperation were identified by multivariable analysis (c statistic=0.60) and summarized into a simple bedside risk score. The risk-score performed well when tested in the validation set (Hosmer-Lemeshow P=0.16). CONCLUSIONS Reoperation for bleeding remains an important morbid event after CABG. Nonetheless, death in patients with this complication has decreased over time. Our risk tool should allow estimation of patients risk for reoperation for bleeding and promote preventive measures when feasible in this at-risk group.
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Abstract
Coronary artery bypass grafting (CABG) is effective in reducing cardiovascular morbidity and mortality in certain high-risk groups. Despite improvement in surgical technique, hemorrhagic complications are a major concern and are likely to affect perioperative morbidity and mortality, length of stay, and hospital expenditures. The use of platelet-directed therapies in this setting is effective in decreasing ischemic complications, yet these agents simultaneously increase the risk of bleeding. Concern about potential hemorrhagic risk from antiplatelet agents in proximity to CABG may influence physicians to discontinue these agents. The benefit of low-dose aspirin given preoperatively is likely to outweigh any hemorrhagic risk. Dual antiplatelet therapy with aspirin and clopidogrel (or aspirin and prasugrel) is associated with a significant increased risk of bleeding and its complications. Additional research is needed to properly evaluate the ischemic benefit versus bleeding risk of aspirin and clopidogrel. Whether reversible P2Y(12) receptor antagonists will mitigate the bleeding risk is unclear at the present time and will require large prospective studies.
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94
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Costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg 2009; 138:687-93. [DOI: 10.1016/j.jtcvs.2009.02.021] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 09/12/2008] [Accepted: 02/02/2009] [Indexed: 11/20/2022]
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95
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Timbie JW, Shahian DM, Newhouse JP, Rosenthal MB, Normand SLT. Composite measures for hospital quality using quality-adjusted life years. Stat Med 2009; 28:1238-54. [PMID: 19184974 DOI: 10.1002/sim.3539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Developing clinically meaningful summary measures of health-care quality is key to inferring quality of care. Current summary measures use a number of different approaches to weight their individual measures but rarely use weights based on clinical 'importance'. Such an approach would help to focus quality improvement efforts on areas likely to have the largest impact on health outcomes. Using coronary artery bypass graft (CABG) surgery as a case study, we weight and combine 11 process, complication, and survival measures to summarize differences in quality-adjusted life expectancy 1 year following surgery for a sample of hospitals. We use a fully Bayesian analysis to estimate 1-year survival outcomes using a hierarchical exponential survival model. We then estimate the expected utility of the year following surgery for each patient using complication probabilities fitted from hierarchical models and utility values from the literature. We estimate quality-adjusted life years (QALYs) for each hospital as the utility-weighted average 1-year survival probability and then estimate 'incremental QALYs' by taking the difference in QALYs for each hospital relative to a comparison group that reflects the average performance of all hospitals in the state. We illustrate our framework by estimating incremental QALYs for 14 hospitals performing CABG surgery in Massachusetts in 2003 and find that a composite measure based on QALYs can change the classification of quality outliers relative to conventional mortality measures.
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Affiliation(s)
- Justin W Timbie
- HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA.
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96
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Herz-Kreislauf-Stillstand und kardiopulmonale Reanimation auf der herzchirurgischen Intensivstation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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97
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Gwozdziewicz M, Olsak P, Lonsky V. Re-operations for bleeding in cardiac surgery: treatment strategy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152:159-62. [PMID: 18795093 DOI: 10.5507/bp.2008.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIMS Cardiac surgery patients are prone to bleeding postoperatively owing to the extensive sternotomy wound, multiple vessel and heart sutures, and disorders of hemostasis. In this study we retrospectively analyzed the outcomes for all patients in our department who were re-operated for bleeding, over a 5 year period. METHODS A total of 4297 patients underwent heart surgery between February 2002 and January 2007, of which 98 (2.3 %) were emergency reoperations for bleeding. We analyzed the process of indication for repeat surgery, possible source of bleeding, and postoperative complications. RESULTS Most (85.7 %) of the reoperated patients had undergone their first operation as an elective cardiac procedure. The mean blood loss before the reoperation was 1557 ml. The studied group was characterized by increased mortality (11.2 %), longer ventilation period (35.1 hours) and ICU (4.5 days) and hospital (13.3 days) stays. The postoperative outcomes did not differ significantly between patients with TEG-detected coagulation disorder and the rest of the patients, or between patients treated with antilysin and those who did not receive antifibrinolytics. CONCLUSIONS It is vital for the indication process leading to reoperation of the bleeding patient to be as short as possible so as to minimize the delay to repeat surgery. Echocardiography including ultrasound of both pleural spaces, and TEG could shorten that time delay, and should always be included when evaluating patients. Platelets should be administered more often, with the use of antifibrinolytics reserved for cases with confirmed fibrinolysis.
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Affiliation(s)
- Marek Gwozdziewicz
- Department of Cardiac Surgery, University Hospital, Olomouc, Czech Republic.
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98
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Surgical Reexploration After Cardiac Operations: Why a Worse Outcome? Ann Thorac Surg 2008; 86:1557-62. [DOI: 10.1016/j.athoracsur.2008.07.114] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 07/30/2008] [Accepted: 07/31/2008] [Indexed: 11/24/2022]
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99
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Balsam LB, Timek TA, Pelletier MP. Factor Eight Inhibitor Bypassing Activity (FEIBA) for Refractory Bleeding in Cardiac Surgery: Review of Clinical Outcomes. J Card Surg 2008; 23:614-21. [DOI: 10.1111/j.1540-8191.2008.00686.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Leora B. Balsam
- Stanford Program in Cardiac Surgery at El Camino Hospital, Mountain View, California
| | - Tomasz A. Timek
- Stanford Program in Cardiac Surgery at El Camino Hospital, Mountain View, California
| | - Marc P. Pelletier
- Stanford Program in Cardiac Surgery at El Camino Hospital, Mountain View, California
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100
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Karkouti K, Beattie WS. Pro: The Role of Recombinant Factor VIIa in Cardiac Surgery. J Cardiothorac Vasc Anesth 2008; 22:779-82. [DOI: 10.1053/j.jvca.2008.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Indexed: 11/11/2022]
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