Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery

Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multicentre European RECORD (REdo Cardiac Operation Research Database) initiative†

OBJECTIVES

Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR.

METHODS

Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis].

RESULTS

Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04).

CONCLUSIONS

RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases.

Effects of autologous priming on blood conservation after cardiac surgery

Objective:

Cardiopulmonary bypass can result in hemodilution due to the crystalloid prime, increasing the need for blood transfusion. Alternative perfusion techniques have the potential to decrease this hemodilution. The objective of this study was to determine whether a protocol of retrograde autologous prime (RAP) and venous antegrade prime (VAP) reduces the need for blood transfusion and increases the hematocrit following cardiac surgery.

Methods:

We performed a retrospective review of 140 consecutive non-randomized patients who underwent cardiac surgery with cardiopulmonary bypass between November 2011 and September 2012. RAP and VAP techniques were used in 70 patients while the other 70 were managed with conventional perfusion strategies. The primary outcome measure was a composite outcome of any blood transfusion or a discharge hematocrit less than 27%.

Results:

Baseline demographics and patient characteristics were similar between the two groups, with the exception of the RAP/VAP group having a lower baseline creatinine. There was a trend toward decreased perioperative blood transfusions in the RAP/VAP group (13/70, 19%) compared with the non-RAP/VAP group (23/70, 33%, p=0.053). RAP/VAP patients had a significantly higher hematocrit at hospital discharge (30.0 ± 4.3% vs. 28.3 ± 4.1%, p=0.012). The number of patients receiving a transfusion or being discharged with an hematocrit less than 27% was significantly less in the RAP/VAP group (21 vs. 41, p=0.001). This effect persisted on multivariable analysis.

Conclusions:

RAP and VAP perfusion techniques may reduce hemodilution, potentially resulting in less blood transfusions and higher postoperative hematocrits. These techniques should be considered in all patients undergoing cardiac surgery with cardiopulmonary bypass.