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Keizman E, Jamal T, Sarantsev I, Ram E, Furman A, Kogan A, Raanani E, Sternik L. Cardiac surgery during wartime in Israel. J Cardiothorac Surg 2024; 19:446. [PMID: 39004766 PMCID: PMC11247751 DOI: 10.1186/s13019-024-02907-4] [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: 02/06/2024] [Accepted: 06/15/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The war that began on October 7th, 2023, has impacted all major tertiary medical centers in Israel. In the largest cardiac surgery department in Israel there has been a surprising increase in the number of open-heart procedures, despite having approximately 50% of surgeons recruited to military service. The purpose of this study is to characterize this increase in the number of operations performed during wartime and assess whether the national crisis has affected patient outcomes. METHODS The study was based on a prospectively collected registry of 275 patients who underwent cardiac surgery or extracorporeal membrane oxygenation (ECMO) during the first two months of war, October 7th 2023 - December 7th 2023, as well as patients that underwent cardiac surgery during the same period of time in 2022 (October 7th, 2022 - December 7th, 2022). RESULTS 120 patients (43.6%) were operated on in 2022, and 155 (56.4%) during wartime in 2023. This signifies a 33.0% increase in open-heart procedures (109 in 2022 vs. 145 in 2023, p-value 0.26). There were no significant differences in the baseline characteristics of patients when comparing the 2022 patients to those in 2023. No significant differences between the two groups were found with regards to intraoperative characteristics or the type of surgery. However, compared to 2022, there was a 233% increase in the number of transplantations in the 2023 cohort (p-value 0.24). Patient outcomes during wartime were similar to those of 2022, including postoperative complications, length of stay, and mortality. CONCLUSIONS Patients who underwent cardiac surgery during wartime presented with comparable outcomes when compared to those of last year despite the increase in cardiac surgery workload. There was an increase in the number of transplants this year, attributed to the unfortunate increase in organ donors.
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Affiliation(s)
- Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel.
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Tel Hashomer, Israel.
| | - Tamer Jamal
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Irena Sarantsev
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Eilon Ram
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Aryel Furman
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Alexander Kogan
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
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Besnier E, Schmidely P, Dubois G, Lemonne P, Todesco L, Aludaat C, Caus T, Selim J, Lorne E, Abou-Arab O. POBS-Card, a new score of severe bleeding after cardiac surgery: Construction and external validation. JTCVS OPEN 2024; 19:183-199. [PMID: 39015466 PMCID: PMC11247224 DOI: 10.1016/j.xjon.2024.04.008] [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: 07/19/2023] [Revised: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 07/18/2024]
Abstract
Objective Bleeding after cardiac surgery leads to poor outcomes. The objective of the study was to build the PeriOperative Bleeding Score in Cardiac surgery (POBS-Card) to predict bleeding after cardiac surgery. Methods We conducted a retrospective cohort study in 2 academic hospitals (2016-2019). Inclusion criteria were adult patients after cardiac surgery under cardiopulmonary bypass. Exclusion criteria were heart transplantation, assistance, aortic dissection, and preoperative hemostasis diseases. Bleeding was defined by the universal definition for perioperative bleeding score ≥2. POBS-Card score was built using multivariate regression (derivation cohort, one center). The performance diagnosis was assessed using the area under the curve in a validation cohort (2 centers) and compared with other scores. Results In total, 1704 patients were included in the derivation cohort, 344 (20%) with bleeding. Preoperative factors were body mass index <25 kg/m2 (odds ratio [OR], 1.48 [1.14-1.93]), type of surgery (redo: OR, 1.76 [1.07-2.82]; combined: OR, 1.81 [1.19-2.74]; ascendant aorta: OR, 1.56 [1.02-2.38]), ongoing antiplatelet therapy (single: OR, 1.50 [1.09-2.05]; double: OR, 2.00 [1.15-3.37]), activated thromboplastin time ratio >1.2 (OR, 1.44 [1.03-1.99]), prothrombin ratio <60% (OR, 1.91 [1.21-2.97]), platelet count <150 g/L (OR, 1.74 [1.17-2.57]), and fibrinogen <3 g/L (OR, 1.33 [1.02-1.73]). In the validation cohort of 597 patients, the area under the curve was 0.645 [0.605-0.683] and was superior to other scores (WILL-BLEED, Papworth, TRUST, TRACK). A threshold >14 predicted bleeding with a sensitivity of 50% and a specificity of 73%. Conclusions POBS-Card score was superior to other scores in predicting severe bleeding after cardiac surgery. Performances remained modest, questioning the place of these scores in the perioperative strategy of bleeding-sparing.
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Affiliation(s)
- Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Univ Rouen Normandie, Inserm U1096, CHU Rouen, Rouen, France
| | - Pierre Schmidely
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Guillaume Dubois
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
| | - Prisca Lemonne
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Lucie Todesco
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Chadi Aludaat
- Department of Cardiac Surgery, Rouen University Hospital, Rouen, France
| | - Thierry Caus
- Department of Cardiac Surgery, Amiens University Hospital, Amiens, France
| | - Jean Selim
- Department of Anesthesiology and Critical Care, Univ Rouen Normandie, Inserm U1096, CHU Rouen, Rouen, France
| | - Emmanuel Lorne
- Anesthesia and Critical Care Medicine, Clinique du Millénaire, Cedex 2, Montpellier, France
| | - Osama Abou-Arab
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
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Pabón-Carrasco M, Cáceres-Matos R, Martínez-Flores S, Luque-Oliveros M. The effectiveness of cell salvage in extracorporeal circulation surgeries in relation to use of health resources after use: A systematic review and meta-analysis. Heliyon 2024; 10:e30459. [PMID: 38720744 PMCID: PMC11077044 DOI: 10.1016/j.heliyon.2024.e30459] [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: 01/12/2024] [Revised: 04/19/2024] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Background Alternatives to allogeneic blood transfusions are sought for resource management reasons and it is necessary to investigate the efficiency and efficacy on Cell Salvage use. The objective of this study is to analyze the effectiveness of the Cell Salvage system in addressing factors related to healthcare service utilization that may lead to increased healthcare expenditure. Methods A systematic review with meta-analysis was conducted through literature search in Medline, CINAHL, Scopus, Web of Science, and Cochrane Library. Inclusion criteria were studies in English/Spanish, without year restriction and Randomized Controlled Trials design, conducted in adults. Results Twenty-six studies were included in the systematic review, involving a total of 4781 patients (nexperimental group = 2365; ncontrol group = 2416). Significant differences favored the Cell Salvage system in units of transfused Red Blood Cells, in terms of units (p = 0.04; SMD = -0.42 95 % CI = -0.83 to -0.02) and individuals (p = 0.001; RR = 0.71, 95 % CI = 0.60 to 0.84) transfused. No significant differences were found in ICU (p = 0.93) and hospital stay duration (p = 0.21), number of reoperations (p = 0.68), and number of units and individuals transfused in terms of platelets (p > 0.05). Conclusions Cell Salvage use holds high potential for reducing healthcare costs and indirectly contributing to improving blood and blood product reserves within blood banks. Results obtained thus far do not provide definitive evidence regarding the duration of hospital stay, ICU stay, need for reoperation, or the quantity of transfused platelets. Therefore, it is recommended to increase the number of studies to assess the impact on the economic models of the Cell Salvage system.
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Affiliation(s)
- Manuel Pabón-Carrasco
- Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, 41009, Sevilla, Spain
- “CTS-1054: Interventions and Health Care, Red Cross (ICSCRE)”, Spain
| | - Rocío Cáceres-Matos
- Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, 41009, Sevilla, Spain
- Research Group CTS-1050: “Complex Care, Chronicity and Health Outcomes”, 6 Avenzoar ST, RI, 41009, Seville, Spain
| | - Salvador Martínez-Flores
- Cardiovascular and Thoracic Surgery Operating Theatre Unit of the Virgen Macarena University Hospital, Seville, Spain
| | - Manuel Luque-Oliveros
- Cardiovascular and Thoracic Surgery Operating Theatre Unit of the Virgen Macarena University Hospital, Seville, Spain
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Ding CY, Qi WH, An YJ, Yuan X, Yao YT. The effect of body mass index on short-term outcomes in patients undergoing off-pump coronary artery bypass grafting surgery: a retrospective study from a single cardiovascular center. J Cardiothorac Surg 2024; 19:86. [PMID: 38342892 PMCID: PMC10860294 DOI: 10.1186/s13019-024-02586-1] [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: 08/07/2023] [Accepted: 01/30/2024] [Indexed: 02/13/2024] Open
Abstract
OBJECTIVE This study is designed to investigate the impact of body mass index (BMI) on the short-term outcomes of patients undergoing off-pump coronary artery bypass graft (OPCAB) surgery. METHODS Data was obtained from 1006 Chinese patients who underwent isolated, primary OPCAB at a high-traffic cardiovascular center during 2020. Subjects were categorized, by BMI, into a low & normal weight (LN) group (BMI < 24 kg/m2), an overweight (OVW) group (24 ≤ BMI < 28 kg/m2), and an obese (OBS) group (BMI ≥ 28 kg/m2). Information pertaining to patients' short-term outcomes (including incidence of mortality and morbidities; duration of postoperative mechanical ventilation; length of stay in the ICU and hospital; postoperative bleeding; etc.) were extracted, and the data from each group were compared. RESULTS The incidences of in-hospital mortality and morbidities were similar for all three groups. The volume of fluid infusion, postoperative bleeding within 24 h and total bleeding in LN group were higher than those in the OBS group (P < 0.001). The hemoglobin level was lower in the LN group than that in the OBS group (P < 0.001). Duration of mechanical ventilation and length of stay in the ICU in the LN group were longer than those in the OBS group (P < 0.001). CONCLUSIONS Our results demonstrate that BMI is not significantly related with short-term outcomes in OPCAB patients. However, we suggest that OPCAB patients with low-normal BMI are more susceptible to post-operative blood loss.
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Affiliation(s)
- Chen-Ying Ding
- Department of Anesthesiology, Hohhot First Hospital, Hohhot, 010030, Inner Mongolia Autonomous Region, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Wen-Hui Qi
- Department of Anesthesiology, Harrison International Peace Hospital, Hengshui, 053000, Hebei Province, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yu-Jie An
- Department of Anesthesiology, The Friendship Hospital of Ili Kazakh Autonomous Prefecture, Yining, 835000, Xinjiang Uygur Autonomous Region, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Xin Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China.
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Goutnik M, Nguyen A, Fleeting C, Patel A, Lucke-Wold B, Laurent D, Wahbeh T, Amini S, Al Saiegh F, Koch M, Hoh B, Chalouhi N. Assessment of Blood Loss during Neuroendovascular Procedures. J Clin Med 2024; 13:677. [PMID: 38337371 PMCID: PMC10856135 DOI: 10.3390/jcm13030677] [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: 11/27/2023] [Revised: 12/31/2023] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Neuroendovascular procedures have generally been considered to have minor or inconsequential blood loss. No study, however, has investigated this question. The purpose of this study is to quantify the blood loss associated with neuroendovascular procedures and identify predictors of blood loss, using hemoglobin change as a surrogate for blood loss. (2) Methods: A retrospective review of 200 consecutive endovascular procedures (diagnostic and therapeutic) at our institution from January 2020 to October 2020 was performed. Patients had to have pre- and post-operative hematocrit and hemoglobin levels recorded within 48 h of the procedure (with no intervening surgeries) for inclusion. (3) Results: The mean age of our cohort was 60.1 years and the male representation was 52.5%. The mean pre-operative hemoglobin/hematocrit was significantly lower among females compared to males (12.1/36.2 vs. 13.0/38.5, p = 0.003, p = 0.009). The mean hemoglobin decrease was 0.5 g/dL for diagnostic angiograms compared to 1.2 g/dL for endovascular interventions (p < 0.0001), and 1.0 g/dL for all procedures combined. In a multivariate linear regression analysis, pre-operative antiplatelet/anticoagulant use was associated with a statistically significant decrease in hemoglobin. (4) Conclusions: Our data support that blood loss from diagnostic angiograms is marginal. Blood loss in endovascular interventions, however, tends to be higher. Pre-operative blood antiplatelet/anticoagulant use and increasing age appear to increase bleeding risk and may require closer patient monitoring.
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Affiliation(s)
- Michael Goutnik
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Andrew Nguyen
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Chance Fleeting
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Aashay Patel
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Dimitri Laurent
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Tamara Wahbeh
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Shawna Amini
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Matthew Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Brian Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
| | - Nohra Chalouhi
- Department of Neurosurgery, University of Florida, Gainesville, FL 32601, USA; (M.G.); (A.N.); (C.F.); (A.P.); (T.W.)
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Pearl RG, Cole SP. Development of the Modern Cardiothoracic Intensive Care Unit and Current Management. Crit Care Clin 2023; 39:559-576. [PMID: 37230556 DOI: 10.1016/j.ccc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The modern cardiothoracic intensive care unit (CTICU) developed as a result of advances in critical care, cardiology, and cardiac surgery. Patients undergoing cardiac surgery today are sicker, frailer, and have more complex cardiac and noncardiac morbidities. CTICU providers need to understand postoperative implications of different surgical procedures, complications that can occur in CTICU patients, resuscitation protocols for cardiac arrest, and diagnostic and therapeutic interventions such as transesophageal echocardiography and mechanical circulatory support. Optimum CTICU care requires a multidisciplinary team with collaboration between cardiac surgeons and critical care physicians with training and experience in the care of CTICU patients.
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Affiliation(s)
- Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589.
| | - Sheela Pai Cole
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589
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Stroo JF, van Steenbergen GJ, van Straten AH, Houterman S, Soliman-Hamad MA. Long-term Outcome of Reexploration for Bleeding After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00377-4. [PMID: 37353424 DOI: 10.1053/j.jvca.2023.06.008] [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] [Received: 03/21/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVES This study aimed to determine the influence of reexploration for bleeding and blood product requirement after coronary artery bypass grafting (CABG) on long-term mortality. DESIGN A retrospective cohort study. SETTING A single-center institution. PARTICIPANTS All patients who underwent CABG between January 1998 and December 2019 were included. INTERVENTIONS The parameters were analyzed to assess the association between reexploration for bleeding and long-term mortality. MEASUREMENTS AND MAIN RESULTS The primary endpoint was all-cause mortality up to the end of follow-up (June 1, 2021). The secondary endpoints were 30-day mortality, duration of admission, blood product transfusion, postoperative use of an intra-aortic balloon pump, deep sternal wound infection, myocardial infarction, and neurologic complications. The Cox proportional hazards model was used to assess the association between reexploration and blood product use and all-cause mortality. Median follow-up was 9.7 years (IQR 5.1-14.6). In total, 576 out of 21,346 (2.7%) patients were reexplored for bleeding. Thirty-day mortality was 6.2% v 1.6% for the reexplored versus not reexplored patients. Reexploration for bleeding was not significantly correlated with long-term mortality (hazard ratio [HR] 1.029; p = 0.068). On the other hand, blood product transfusion (HR = 1.135; p < 0.001), and in particular, packed red blood cell (pRBC) transfusion (HR = 1.139; p < 0.001), was significantly associated with higher long-term mortality. After multivariate Cox regression using ≥5 pRBC transfused as a cut-off point, reexploration for bleeding was not significantly associated with long-term mortality (HR 0.982; p = 0.813). Receiving ≥5 pRBCs was significantly associated with higher long-term mortality (HR 1.249; p < 0.001). CONCLUSION Reexploration for bleeding was significantly associated with higher 30-day mortality but not with long-term mortality. Poorer long-term mortality was attributed to patient characteristics and higher use of postoperative blood products.
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Affiliation(s)
- Jasmijn F Stroo
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Albert Hm van Straten
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Saskia Houterman
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
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Ripoll JG, Warner MA, Hanson AC, Marquez A, Dearani JA, Nuttall GA, Kor DJ, Mauermann WJ, Smith MM. Coagulation Tests and Bleeding Classification After Cardiopulmonary Bypass: A Prospective Study. J Cardiothorac Vasc Anesth 2023; 37:933-941. [PMID: 36863984 PMCID: PMC10149589 DOI: 10.1053/j.jvca.2023.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE No recent prospective studies have analyzed the accuracy of standard coagulation tests and thromboelastography (TEG) to identify patients with excessive microvascular bleeding following cardiopulmonary bypass (CPB). The aim of this study was to assess the value of coagulation profile tests, as well as TEG, for the classification of microvascular bleeding after CPB. DESIGN A prospective observational study. SETTING At a single-center academic hospital. PARTICIPANTS Patients ≥18 years of age undergoing elective cardiac surgery. INTERVENTIONS Qualitative assessment of microvascular bleeding post-CPB (surgeon and anesthesiologist consensus) and the association with coagulation profile tests and TEG values. MEASUREMENTS AND MAIN RESULTS A total of 816 patients were included in the study-358 (44%) bleeders and 458 (56%) nonbleeders. Accuracy, sensitivity, and specificity for the coagulation profile tests and TEG values ranged from 45% to 72%. The predictive utility was similar across tests, with prothrombin time (PT) (62% accuracy, 51% sensitivity, 70% specificity), international normalized ratio (INR) (62% accuracy, 48% sensitivity, 72% specificity), and platelet count (62% accuracy, 62% sensitivity, 61% specificity) displaying the highest performance. Secondary outcomes were worse in bleeders versus nonbleeders, including higher chest tube drainage, total blood loss, transfusion of red blood cells, reoperation rates (p < 0.001, respectively), readmission within 30 days (p = 0.007), and hospital mortality (p = 0.021). CONCLUSIONS Standard coagulation tests and individual components of TEG in isolation agree poorly with the visual classification of microvascular bleeding after CPB. The PT-INR and platelet count performed best but had low accuracy. Further work is warranted to identify better testing strategies to guide perioperative transfusion decisions in cardiac surgical patients.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Statistician, Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Spadaccio C, Rose D, Nenna A, Taylor R, Bittar MN. Early Re-Exploration versus Conservative Management for Postoperative Bleeding in Stable Patients after Coronary Artery Bypass Grafting: A Propensity Matched Study. J Clin Med 2023; 12:jcm12093327. [PMID: 37176767 PMCID: PMC10179715 DOI: 10.3390/jcm12093327] [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: 01/31/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Postoperative bleeding requiring re-exploration in cardiac surgery has been associated with complications impacting short-term outcomes and perioperative survival. Many aspects of decision-making for re-exploration still remain controversial, especially in hemodynamically stable patients with significant but not acutely cumulating chest drain output. We investigated the impact of re-exploratory surgery on short-term outcomes in a "borderline population" of CABG patients who experienced significant non-acute bleeding, but that were not in critically hemodynamic unstable conditions. METHODS A prospectively collected database of 8287 patients undergoing primary isolated elective CABG was retrospectively interrogated. A population of hemodynamically stable patients experiencing significant non-acute or rapidly cumulating bleeding (>1000 mL of blood loss in 12 h, <200 mL per hour in the first 5 h) with normal platelet and coagulation tests was identified (N = 1642). Patients belonging to this group were re-explored (N = 252) or treated conservatively (N = 1390) based on the decision of the consultant surgeon. Clinical outcomes according to the decision-making strategy were compared using a propensity score matching (PSM) approach. RESULTS After PSM, reoperated patients exhibited significantly higher overall blood product consumption (88.4% vs. 52.6% for red packed cells, p = 0.001). The reoperated group experienced higher rates of respiratory complications (odds ratio 5.8 [4.29-7.86] with p = 0.001 for prolonged ventilation), prolonged stay in intensive care unit (coefficient 1.66 [0.64-2.67] with p = 0.001) and overall length of stay in hospital (coefficient 2.16 [0.42-3.91] with p = 0.015) when compared to conservative management. Reoperated patients had significantly increased risk of multiorgan failure (odds ratio 4.59 [1.37-15.42] with p = 0.014) and a trend towards increased perioperative mortality (odds ratio 3.12 [1.08-8.99] with p = 0.035). CONCLUSIONS Conservative management in hemodynamically stable patients experiencing significant but non-critical or emergency bleeding might be a safe and viable option and might be advantageous in terms of reduction of postoperative morbidities and hospital stay.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - David Rose
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - Antonio Nenna
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rebecca Taylor
- Research and Development, Blackpool Teaching Hospitals, Blackpool FY3 8NR, UK
| | - Mohamad Nidal Bittar
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
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10
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Shou BL, Aravind P, Ong CS, Alejo D, Canner JK, Etchill EW, DiNatale J, Prokupets R, Esfandiary T, Lawton JS, Schena S. Early Reexploration for Bleeding Is Associated With Improved Outcome in Cardiac Surgery. Ann Thorac Surg 2023; 115:232-239. [PMID: 35952856 DOI: 10.1016/j.athoracsur.2022.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Reexploration after cardiac surgery, most frequently for bleeding, is a quality metric used to assess surgical performance. This may cause surgeons to delay return to the operating room in favor of attempting nonoperative management. This study investigated the impact of the timing of reexploration on morbidity and mortality. METHODS This study was a single-institution retrospective review of all adult cardiac surgery patients from July 2010 to June 2020. Time to reexploration was assessed, and outcomes were compared across increasing time intervals. Reported bleeding sites were classified into 5 groups, and bleeding rate (chest tube output) was compared across bleeding sites. Univariable analysis was performed using the Fisher exact and Kruskal-Wallis tests. Multivariable logistic regression models were used for risk-adjusted analyses. RESULTS Of 10 070 eligible patients, 251 (2.5%) required reexploration for postoperative bleeding. The most common site of bleeding was "any suture line" (n = 70; 28%). Interestingly, in 30% of cases (n = 75) "no active bleeding" site was reported. The highest rate of bleeding (mL/h) was observed in the "any mediastinal structure" group (median, 450; interquartile range [IQR], 185, 8878), and the lowest rate was noted in the "no active bleeding" group (median, 151.2; IQR, 102, 270). Both morbidity rates (0-4 hours, 12.3% vs 25-48 hours, 37.5%; P = .001) and mortality rates (0-4 hours, 3.1% vs 25-48 hours, 43.8%; P = .001) escalated significantly with increasing time to reexploration. CONCLUSIONS Delayed reexploration for bleeding after cardiac surgery is associated with increased risk for morbidity and mortality. Early surgical intervention, particularly within 4 hours, may improve outcomes. Implications from using reoperation as a performance metric may lead to unnecessary delay and patient harm.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Pathik Aravind
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Joseph K Canner
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Joseph DiNatale
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Rochelle Prokupets
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tina Esfandiary
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Stefano Schena
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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11
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Li Z, Wu LL, Gao J, Wang Y, Zhao X, Xie D. Is VATS approach suitable in re-operations for postoperative hemothorax after pulmonary resection? Data analysis in a big volume thoracic center. J Cardiothorac Surg 2022; 17:310. [PMID: 36517895 PMCID: PMC9753259 DOI: 10.1186/s13019-022-02099-9] [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: 05/03/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE This study explored the safety and of feasibility of video-assisted thoracoscopy (VATS) in re-operations for post-operative hemothorax. METHODS The clinical data of patients underwent re-operations due to post-operative hemothorax after pulmonary resection in Shanghai Pulmonary Hospital from 2006 to 2018 were retrospectively analysed. The incidence of re-operations were analyzed. The mortality and morbidity were compared between thoracotomy and thoracoscopic procedure for re-exploration. RESULTS A total of 114 patients were included. The annual incidence rate ranged from 0.21 to 0.54%; the perioperative mortality was 2.6%; there were 114 cases of re-operations for hemothorax after 2012, including 62 cases in thoracoscopy group and 52 cases in open group. The durations of chest-tube drainage (7.2 ± 3.9 days vs 10.9 ± 12.0 days, P = 0.001) and length of stay in hospital (13.7 ± 6.7 days vs 18.9 ± 10.6 days, P = 0.002) in the thoracoscopic group were shorter than those in the open group. The thoracoscopic group had fewer post-operative complications as well (P = 0.023). Meanwhile, post-operative complications in the delayed group were significantly higher than those in the non-delayed group, with a longer length of hospital stay and higher hospitalization costs. CONCLUSION Complete VATS is safe and feasible for re-operation due to post-operative hemothorax and can be an alternative to thoracotomy. Delayed re-operations are associated with more post-operative complications and higher costs.
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Affiliation(s)
- Zhixin Li
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200433 People’s Republic of China
| | - Lei-Lei Wu
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200433 People’s Republic of China
| | - Jiani Gao
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200433 People’s Republic of China
| | - Yichao Wang
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200433 People’s Republic of China
| | - Xiaogang Zhao
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200433 People’s Republic of China
| | - Dong Xie
- grid.24516.340000000123704535Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, No. 507 Zhengmin Road, Shanghai, 200433 People’s Republic of China
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12
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Analysis of prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. J Cardiothorac Surg 2022; 17:82. [PMID: 35461233 PMCID: PMC9034579 DOI: 10.1186/s13019-022-01825-7] [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: 05/25/2021] [Accepted: 04/08/2022] [Indexed: 12/02/2022] Open
Abstract
Objective To explore the prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. Methods We retrospectively analyzed the data of 100 patients who underwent unplanned re-exploration after cardiovascular surgery in our hospital between May 2010 and May 2020. There were 77 males and 23 females, aged (55.1 ± 15.2) years. Demographic characteristics, surgical information, perioperative complications were collected to establish a database. These patients were divided into surviving and non-surviving groups according to in-hospital mortality. Logistic regression was used for multivariable analysis to explore the prognostic factors of in-hospital mortality. These statistically significant indicators were selected for drawing the receiver operating characteristic curve of the evaluation model, calculating the area under the curve (AUC) and evaluating the effectiveness of the new model with Hosmer–Lemeshow C-statistic. Results In-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery was 26.0% (26/100). Multivariate logistics regression revealed that the operation time of unplanned re-exploration, the worst blood creatinine value within 48 h before the re-exploration, the worst lactate value within 24 h after the re-exploration, cardiac insufficiency, respiratory insufficiency, and acute kidney injury were independent prognostic factors (P < 0.05). The AUC of the new assessment model constituted by these prognostic factors was 0.910, and the Hosmer–Lemeshow C-statistic was 4.153 (P = 0.762). Conclusions Operation time of unplanned re-exploration, worst serum creatinine value within 48 h before re-exploration, worst lactate value within 24 h after re-exploration, cardiac insufficiency, respiratory insufficiency, and acute kidney injury are the main prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. Identifying these prognostic factors can effectively facilitate preventive measures and improve patient outcomes.
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13
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Jeong D, Kim SY, Gu JY, Kim HK. Assessment of Rotational Thromboelastometry and Thrombin Generation Assay to Identify Risk of High Blood Loss and Re-Operation After Cardiac Surgery. Clin Appl Thromb Hemost 2022; 28:10760296221123310. [PMID: 36124381 PMCID: PMC9490460 DOI: 10.1177/10760296221123310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: We aimed to investigate parameters for prediction of post-operative blood loss and re-operation in patients who underwent cardiopulmonary bypass. Methods: Thrombin generation assay, activated partial thromboplastin time, activated clotting time and rotational thromboelastometry (ROTEM) tests were performed at 4 time points in 65 patients: before skin incision (T1), after heparin injection (T2), after protamine reversal (T3) and before skin closure (T4). Results: Pre-operative endogenous thrombin potential (ETP) and peak thrombin levels were significantly lower in patients with high post-operative blood loss (≥ 800 mL) within 24 h than in those with low blood loss (< 800 mL). Clotting time (CT), maximal clotting firmness, clotting firmness time and alpha angle values of ROTEM measured at T2, T3 or T4 were significant predictors for high post-operative blood loss. An increase in CT-EXTEM over 4 time points was significant in patients who had a re-operation within 48 h compared to their counterparts. Conclusions: This study indicates that pre-operative ETP could predict high post-operative blood loss and that intra-operative ROTEM also helps to stratify risks of high post-operative blood loss and re-operation.
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Affiliation(s)
- Dajeong Jeong
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seon Young Kim
- Department of Laboratory Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ja-Yoon Gu
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Hyun Kyung Kim, MD, PhD, Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea.
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14
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Konstanty-Kalandyk J, Kędziora A, Mazur P, Litwinowicz R, Kapelak B, Piątek J. Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk-A propensity score matched analysis. PLoS One 2021; 16:e0261176. [PMID: 34937067 PMCID: PMC8694429 DOI: 10.1371/journal.pone.0261176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 11/28/2021] [Indexed: 11/18/2022] Open
Abstract
Background Bilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels. Methods A propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections. Results A total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577). Conclusions In-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.
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Affiliation(s)
- Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
- Jagiellonian University Medical College, Institute of Cardiology, Krakow, Poland
| | - Anna Kędziora
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
- Jagiellonian University Medical College, Institute of Cardiology, Krakow, Poland
- * E-mail:
| | - Piotr Mazur
- Jagiellonian University Medical College, Institute of Cardiology, Krakow, Poland
| | - Radosław Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
- Jagiellonian University Medical College, Institute of Cardiology, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
- Jagiellonian University Medical College, Institute of Cardiology, Krakow, Poland
| | - Jacek Piątek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
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15
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Fazlinović S, Wallinder A, Dellborg M, Furenäs E, Eriksson P, Synnergren M, Lidén H. Outcome and survival after open heart surgery for adults with congenital heart disease - a single center experience. SCAND CARDIOVASC J 2021; 55:345-353. [PMID: 34672849 DOI: 10.1080/14017431.2021.1983639] [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: 10/20/2022]
Abstract
Introduction. Congenital heart disease (CHD) is the most common type of birth defect today. The adult congenital heart disease (ACHD) population is constantly growing and becoming older and more patients require cardiac surgery. The objective of this study was to review the surgical outcome of the open heart procedures performed on ACHD patients in the last 10 years at Sahlgrenska University Hospital (SUH) through a retrospective descriptive cohort study. Methods. A retrospective data collection was performed for 421 patients who underwent a total of 439 surgical procedures between 2009 and 2018 at the Cardiothoracic department in SUH. The primary outcomes were early (<30 days) and late survival. Secondary outcomes were postoperative complications and independent risk factors for postoperative complications. Results. 30-day mortality was 1.9%. Long-term survival after 3, 5 and 10 years were 96% ± 1, 94.3% ± 1.3 and 92.4% ± 1.8. 82 major complications occurred after 46 procedures (11.6%). The most common major complication was re-exploration due to hemorrhage. Risk factors for major complications were acute surgery and prolonged extracorporeal circulation time. 173 minor complications occurred after 90 procedures (22.5%). The most common minor complication was prolonged intensive care unit stay (>48 h). Conclusion. This study presents satisfactory early and midterm survival. The survival and frequency of major postoperative complications are well in line with what other studies have presented. Patients undergoing resternotomies had no increased risk for mortality or postoperative complications.
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Affiliation(s)
- Sanin Fazlinović
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,ACHD-unit, Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Furenäs
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,ACHD-unit, Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Eriksson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,ACHD-unit, Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Synnergren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Lidén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
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16
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Rogers AL, Allman RD, Fang X, Kindell LC, Nifong LW, Degner BC, Akhter SA. Thromboelastography-Platelet Mapping Allows Safe and Earlier Urgent Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 113:1119-1125. [PMID: 34437860 DOI: 10.1016/j.athoracsur.2021.07.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/01/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current STS guidelines recommend delaying CABG for several days or performing platelet function testing in stable patients who received P2Y12 inhibitors. Our program routinely uses thromboelastography-platelet mapping (TEG-PM) to expedite CABG in P2Y12 non-responders (NR). We hypothesize that P2Y12 NR had no difference in LOS to surgery and blood product transfusion compared to patients undergoing urgent inpatient CABG not treated with a P2Y12 inhibitor. METHODS A total of 221 patients from 2015-2019 were P2Y12 NR based on TEG-PM result of < 50% ADP inhibition. The control group was 232 consecutive patients who also had urgent inpatient CABG but were not treated pre-operatively with a P2Y12 inhibitor. Exclusion criteria were identical between groups. RESULTS Sixty-seven percent of inpatient CABG patients who were treated pre-operatively with a P2Y12 inhibitor were NR. The mean number of days from cardiac surgical consultation to CABG in the TEG-PM NR group was 1.6 ± 0.1 versus 2.1 ± 0.1 in the control group (p<0.01). The mean total number of blood product units transfused was 1.6 ± 0.2 in the TEG-PM NR group versus 1.6 ± 0.4 in controls (p=0.91). CONCLUSIONS Our results demonstrate a very high incidence of P2Y12 non-responders in patients undergoing urgent CABG at our program. These patients underwent surgery at least 3 days earlier than STS recommendations and common practice with no difference in transfusion requirement. Routine use of TEG-PM to identify P2Y12 NR can safely decrease pre-operative hospital LOS and associated cost and improve resource utilization and patient satisfaction.
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Affiliation(s)
- Austin L Rogers
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Robert D Allman
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Xiangming Fang
- Department of Biostatistics, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina
| | - Linda C Kindell
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Leslie W Nifong
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Benjamin C Degner
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Shahab A Akhter
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina.
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17
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van Steenbergen GJ, van Straten AHM, Kabak S, van Veghel D, Dekker L, Soliman-Hamad MA. Impact of preoperative antithrombotic therapy in patients undergoing elective isolated coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2021; 33:702-709. [PMID: 34337650 DOI: 10.1093/icvts/ivab176] [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: 03/19/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG). METHODS Patients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence). RESULTS A total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29-9.83)] and increased use of blood products [37.5% vs 20.3%, P < 0.001; OR 2.35 (1.58-3.49)]. In 122 matched subgroup patients, non-adherence was associated with an increased risk of re-exploration [10.7% vs 3.3%, P = 0.044; OR 3.52 (1.11-11.12)] and increased blood product use [51.6% vs 25.4%, P < 0.001; OR 3.13 (1.83-5.38)]. Secondary end points were not significantly different among the main study groups and subgroups. CONCLUSIONS Preoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.
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Affiliation(s)
- Gijs J van Steenbergen
- Cardiothoracic surgery department, Catharina Heart Centre, Catharina Hospital, ZA Eindhoven, Netherlands
| | - Albert H M van Straten
- Cardiothoracic surgery department, Catharina Heart Centre, Catharina Hospital, ZA Eindhoven, Netherlands
| | - Serhat Kabak
- Cardiothoracic surgery department, Catharina Heart Centre, Catharina Hospital, ZA Eindhoven, Netherlands
| | - Dennis van Veghel
- Cardiothoracic surgery department, Catharina Heart Centre, Catharina Hospital, ZA Eindhoven, Netherlands
| | - Lukas Dekker
- Cardiothoracic surgery department, Catharina Heart Centre, Catharina Hospital, ZA Eindhoven, Netherlands.,Department of Biomedical Technology, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Mohamed A Soliman-Hamad
- Cardiothoracic surgery department, Catharina Heart Centre, Catharina Hospital, ZA Eindhoven, Netherlands
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18
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Udelsman BV, Soni M, Madariaga ML, Fintelmann FJ, Best TD, Li SSY, Chang DC, Gaissert HA. Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy. Eur J Cardiothorac Surg 2021; 57:462-470. [PMID: 31562514 DOI: 10.1093/ejcts/ezz266] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management. METHODS We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days. RESULTS Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group. CONCLUSIONS Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.
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Affiliation(s)
- Brooks V Udelsman
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA
| | - Monica Soni
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | | | | | - Till D Best
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Selena Shi-Yao Li
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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19
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Bailly A, Gaillard C, Cadiet J, Fortuit C, Roux F, Morin H, Desanlis E, LE Teurnier Y, Miguet B, Robert D, Silleran J, Rigal JC, LE Thuaut A, Pere M, Roussel JC, Rozec B. Evaluation of the impact of HMS Plus on postoperative blood loss compared with ACT Plus in cardiac surgery. Minerva Anestesiol 2021; 87:1191-1199. [PMID: 34102807 DOI: 10.23736/s0375-9393.21.15482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The standardized management of anticoagulation during the cardiopulmonary bypass seems inaccurate because of patients and surgeries variability. This study evaluates if an individualized management of heparin and protamine guided by the HMS Plus system during cardiopulmonary bypass could reduce postoperative blood loss. METHODS We conducted a prospective, controlled, unblinded, single-center study. 188 patients operated for cardiac surgery were included. Patients were divided in ACT Plus group (standardized approach) and HMS Plus group (individualized approach). The primary outcome was blood-loss volume during the first 24 postoperative hours. The main secondary outcomes were the need for allogeneic blood transfusions and the final protamine/heparin ratio. RESULTS There was no difference between the two groups for baseline characteristics. Medium bloodloss volume (±DS) in the ACT Plus group was 522 mL ±260 mL vs. 527 mL ±255 mL in the HMS Plus group (P = 0.58). The final protamine/heparin ratio (±DS) in the ACT Plus group was 0.94 ±0.1 vs. 0.58 ± 0.1 in the HMS Plus group (P < 0.0001). The transfusion rate during surgery in the ACT Plus group was 25% vs. 14% in the HMS Plus group (P = 0.09). CONCLUSIONS HMS Plus did not reduce the mean blood-loss volume during the first 24 postoperative hours compared with ACT Plus. Its utility for potential transfusion rate reduction remains to be proven.
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Affiliation(s)
- Arthur Bailly
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France -
| | - Côme Gaillard
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Julien Cadiet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - François Roux
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Hélène Morin
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Enguerrand Desanlis
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Yann LE Teurnier
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Bertrand Miguet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - David Robert
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jacqueline Silleran
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Jean-Christophe Rigal
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France
| | - Aurélie LE Thuaut
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Morgane Pere
- Department of Methodology and Biostatistics, University Hospital of Nantes, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, Université de Nantes, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Laennec, CHU Nantes, Nantes, France.,Université de Nantes, CHU Nantes, Nantes, France
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20
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Elassal AA, Al-Ebrahim KE, Debis RS, Ragab ES, Faden MS, Fatani MA, Allam AR, Abdulla AH, Bukhary AM, Noaman NA, Eldib OS. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg 2021; 16:166. [PMID: 34099003 PMCID: PMC8183590 DOI: 10.1186/s13019-021-01545-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
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Affiliation(s)
- Ahmed Abdelrahman Elassal
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | | | - Ragab Shehata Debis
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ehab Sobhy Ragab
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | | | | | - Amr Ragab Allam
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Department of Cardiac Surgery, Naser Institute of Research and Treatment, Cairo, Egypt
| | - Ahmed Hasan Abdulla
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Alahrar Hospital, Zagazig, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Saber Eldib
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
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21
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Ul Islam M, Ahmad I, Khan B, Jan A, Ali N, Hassan Khan W, Farooq O, Khan H, Ahmad Ali F, Shahid M. Early Chest Re-Exploration for Excessive Bleeding in Post Cardiac Surgery Patients: Does It Matter? Cureus 2021; 13:e15091. [PMID: 34159003 PMCID: PMC8212849 DOI: 10.7759/cureus.15091] [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] [Indexed: 11/14/2022] Open
Abstract
Introduction Re-explorations after open-heart surgery are often required if the patient is bleeding or shows features of cardiovascular instability and does not improve with conservative measures. Our study aims to determine whether timely re-exploration of patients who are bleeding has an impact on the morbidity and mortality of the patients. Methods A retrospective analysis of 75 patients that underwent open-heart surgery and subsequently underwent chest re-exploration for excessive bleeding between March 2018 and March 2020. Patients who were reopened post-op for indications other than excessive bleeding were excluded. Results A total number of cases were 700, out of which 75 (9.3%) patients were reopened, as compared to the literature, which shows worldwide 2-11% being reopened. Post-operative drain output was 1000ml to 1500ml in 47 (62.7%) and more than 1500ml in 28 (37.3%) patients before they were reopened. In 67 (89.3%) patients, three to five units of blood were transfused, and in eight (10.7%) patients, more than five units of blood were transfused. We believe our mortality in the reopened patients was low, because of timely intervention and early re-exploration, and is probably the reason why our figures land in a higher range (2-11%) of reopened cases (9.3%). Reopening time was less than five hours in 49 (65.3%) patients and less than 10 hours in 26 (34.7%) patients in our study. We tried to minimize the loss of blood and re-explored the patients before they lose excessive blood, the average time for reopening in our study was less than 10 hours. The average intensive care unit (ICU) stay was 4.2 days (range three to six days). Wound infections were reported in one of three patients. There was no mortality in these patients. Surgical site of bleeding was identified in 54 (72%) patients and no particular site was found in 21 (28%) patients. Suggesting that it is common to have a surgical bleeder than coagulopathy induced bleeding in post-cardiac surgery patients Conclusions We believe our low mortality (0%) is due to early reopening in patients who are bleeding excessively after cardiac surgery.
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Affiliation(s)
| | - Imtiaz Ahmad
- Anesthesiology, Rehman Medical Institute, Peshawar, PAK
| | - Bahauddin Khan
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Azam Jan
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Niaz Ali
- Cardiac Surgery, Northwest School of Medicine, Peshawar, PAK
| | | | - Omer Farooq
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Hooria Khan
- Radiology, Hayatabad Medical Complex, Peshawar, PAK
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22
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Tran Z, Williamson C, Hadaya J, Verma A, Sanaiha Y, Chervu N, Gandjian M, Benharash P. Trends and Outcomes of Surgical Re-exploration Following Cardiac Operations in the United States. Ann Thorac Surg 2021; 113:783-792. [PMID: 33878310 DOI: 10.1016/j.athoracsur.2021.04.011] [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: 12/24/2020] [Revised: 04/03/2021] [Accepted: 04/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Surgical re-exploration following cardiac surgery has been associated with increased in-hospital complications and mortality in limited series. The present study examined trends in reoperation and its impact on clinical outcomes and resource use in a nationally-representative cohort. We sought to determine patient and hospital factors associated with re-exploration and reoperative mortality, defined as failure-to-rescue-surgical (FTR-S). METHODS Adult hospitalizations entailing cardiac operations (coronary artery bypass and/or valve) were identified using the 2005-2018 National Inpatient Sample. Procedures were tabulated using International Classification of Diseases codes. Hospitals were ranked into tertiles according to risk-adjusted mortality, with the lowest stratified as high-performing. Multivariable regression models examined factors associated with re-exploration as well as clinical outcomes including FTR-S and resource utilization. RESULTS Of an estimated 3,490,245 hospitalizations, 78,003 (2.23%) required re-exploration with decreasing incidence over time. Valvular procedures, preoperative intra-aortic balloon pump and liver disease were associated with greater likelihood of re-exploration. Reoperation was associated with increased odds of mortality (adjusted odds ratio (AOR): 3.86, 95%CI: 3.61-4.12), perioperative complications and resource utilization. Increasing time from index operation to re-exploration was associated with higher odds of mortality (AOR:1.10/day, 95%CI: 1.07-1.12). High-performing hospitals were associated with lower odds of re-exploration (AOR: 0.88, 95%CI: 0.82-0.95) and FTR-S (AOR: 0.29, 95%CI: 0.23-0.35). CONCLUSIONS Surgical re-exploration following cardiac surgery has declined over time. High performing hospitals demonstrated lower rates of re-exploration and subsequent failure-to-rescue. Although unable to identify specific practices, our study highlights the presence of significant variation in takeback rates and further study of underlying factors is warranted.
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Affiliation(s)
- Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles.
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23
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Sun D, Schaff HV, Nishimura RA, Geske JB, Dearani JA, Lahr BD, Ommen SR. Impact of Body Mass Index on Outcome of Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy. Ann Thorac Surg 2021; 113:519-526. [PMID: 33774005 DOI: 10.1016/j.athoracsur.2021.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/19/2021] [Accepted: 03/15/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Obesity is highly prevalent in patients with obstructive hypertrophic cardiomyopathy (HCM). In this study, we investigated the impact of body mass index (BMI) in patients undergoing septal myectomy (SM) for obstructive HCM. METHODS We reviewed 2,746 patients who underwent transaortic SM for obstructive HCM from February 1993 through September 2018. Patients were stratified into 3 groups based on BMI (normal weight < 25 kg/m2, overweight 25 to < 30 kg/m2, and obese ≥ 30 kg/m2). RESULTS Preoperatively, median left ventricular outflow tract (LVOT) gradient was 58 mmHg, and there was no difference in gradients across BMI strata (P=0.35). Obese patients had lower percentage with moderate or greater mitral valve regurgitation (45.8%) compared to normal (52.9%) and overweight (55.4%) patients (P<0.001). However, patients with higher BMI were more likely to have New York Heart Association class III/IV limitation at presentation (P<0.001). After myectomy, both anteroseptal thickness (P=0.115) and LVOT gradient (P=0.210) did not differ between groups. There were 14 (0.5%) deaths < 30 days postoperatively and the risk was similar across BMI strata (P=0.448). Model-estimated changes in average BMI at 10 years post procedure showed stratum-specific increases ranging from 0.60 to 1.56 kg/m2. During a median (IQR) follow-up of 7.2 (3.2-13.3) years, higher BMI was associated with reduced survival after adjusting for baseline covariates (P=0.001). CONCLUSIONS Septal myectomy is safe and effective in HCM patients with obesity, but risk of late mortality increased with increasing BMI. Attention to risk factor management through weight loss may improve late results after SM.
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Affiliation(s)
- Daokun Sun
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Brian D Lahr
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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24
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Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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25
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Biaou G, Sebestyen A, Durand M, Albaladejo P, Chavanon O. Early postoperative bleeding after isolated coronary bypasses: Changes over a period of 20 years - An observational study. Transfus Clin Biol 2021; 28:180-185. [PMID: 33578020 DOI: 10.1016/j.tracli.2021.02.001] [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: 11/06/2020] [Revised: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The objectives were to analyze the evolution of the postoperative bleeding after coronary artery bypass grafting and to determine which factors impacted on this evolution. METHODS This is a single-center retrospective study including 4590 patients undergoing coronary bypass surgery between 1995 and 2017. The study period was divided into 3 same-sized periods. We analyzed the evolution of the bleeding according to: the chest volume bleeding over the first 24hours, the severity and the rate of transfusion during the hospital stay. Intrahospital outcomes were compared between "minor" and "major" bleedings. The risk factors of major bleeding were analyzed by multiple logistic regression. RESULTS The chest volume decreased particularly during the first years of the study period. Major bleedings decreased over the periods (7.3%, 4.9% and 3.8% respectively, P<0.0001), as did the rate of transfusion (26.4%, 23.5% and 19.6% respectively, P<0.0001). Major bleedings were correlated with hospital mortality (8.2% versus 1.1%, P<0.0001). The risk factors of major bleeding were the period 1 (1995 to 2003), a renal failure, a resternotomy, the EuroSCORE, the hematocrit prior to cardiopulmonary bypass and the duration of cardiopulmonary bypass. CONCLUSIONS Postoperative bleeding decreased mainly in the 1990s. Progressive changes in bleeding prevention and blood recovery, surgical techniques, haemoglobin threshold for transfusion decision and practitioners' experience have contributed to these results and must be continued to optimize the postoperative outcomes.
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Affiliation(s)
- G Biaou
- Cardiac Surgery Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
| | - A Sebestyen
- Cardiac Surgery Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France.
| | - M Durand
- Anesthesia and Intensive Care Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
| | - P Albaladejo
- Anesthesia and Intensive Care Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
| | - O Chavanon
- Cardiac Surgery Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
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26
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Brown JA, Kilic A, Aranda-Michel E, Navid F, Serna-Gallegos D, Bianco V, Sultan I. Long-Term Outcomes of Reoperation for Bleeding After Cardiac Surgery. Semin Thorac Cardiovasc Surg 2021; 33:764-773. [DOI: 10.1053/j.semtcvs.2020.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 01/12/2023]
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27
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Zheng NS, Warner JL, Osterman TJ, Wells QS, Shu XO, Deppen SA, Karp SJ, Dwyer S, Feng Q, Cox NJ, Peterson JF, Stein CM, Roden DM, Johnson KB, Wei WQ. A retrospective approach to evaluating potential adverse outcomes associated with delay of procedures for cardiovascular and cancer-related diagnoses in the context of COVID-19. J Biomed Inform 2021; 113:103657. [PMID: 33309899 PMCID: PMC7728428 DOI: 10.1016/j.jbi.2020.103657] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/10/2020] [Accepted: 12/07/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE During the COVID-19 pandemic, health systems postponed non-essential medical procedures to accommodate surge of critically-ill patients. The long-term consequences of delaying procedures in response to COVID-19 remains unknown. We developed a high-throughput approach to understand the impact of delaying procedures on patient health outcomes using electronic health record (EHR) data. MATERIALS AND METHODS We used EHR data from Vanderbilt University Medical Center's (VUMC) Research and Synthetic Derivatives. Elective procedures and non-urgent visits were suspended at VUMC between March 18, 2020 and April 24, 2020. Surgical procedure data from this period were compared to a similar timeframe in 2019. Potential adverse impact of delay in cardiovascular and cancer-related procedures was evaluated using EHR data collected from January 1, 1993 to March 17, 2020. For surgical procedure delay, outcomes included length of hospitalization (days), mortality during hospitalization, and readmission within six months. For screening procedure delay, outcomes included 5-year survival and cancer stage at diagnosis. RESULTS We identified 416 surgical procedures that were negatively impacted during the COVID-19 pandemic compared to the same timeframe in 2019. Using retrospective data, we found 27 significant associations between procedure delay and adverse patient outcomes. Clinician review indicated that 88.9% of the significant associations were plausible and potentially clinically significant. Analytic pipelines for this study are available online. CONCLUSION Our approach enables health systems to identify medical procedures affected by the COVID-19 pandemic and evaluate the effect of delay, enabling them to communicate effectively with patients and prioritize rescheduling to minimize adverse patient outcomes.
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Affiliation(s)
- Neil S Zheng
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy L Warner
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Travis J Osterman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Quinn S Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiao-Ou Shu
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen A Deppen
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seth J Karp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shon Dwyer
- Vanderbilt University Adult Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
| | - QiPing Feng
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy J Cox
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA; Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Josh F Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Kevin B Johnson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
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28
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Rodino AM, Henderson JB, Dobbins KF, Rubin DT, Hollis IB. Impact of Thrombocytopenia on Postoperative Bleeding Incidence in Patients Receiving Aspirin Following Coronary Artery Bypass Grafting. J Pharm Pract 2020; 35:223-228. [PMID: 33084455 DOI: 10.1177/0897190020966193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early postoperative aspirin following coronary artery bypass graft (CABG) surgery has been shown to maintain bypass graft patency, reduce mortality, and prevent adverse cardiovascular events. Despite this known benefit, aspirin may be delayed due to thrombocytopenia and perceived higher bleeding risk. The purpose of this study was to assess the impact of postoperative platelet count on bleeding in patients receiving aspirin after CABG. METHODS A retrospective analysis included all patients who underwent CABG surgery at our institution from April 2014 to June 2018 and received aspirin within 24 hours. The primary outcome was International Society on Thrombosis and Hemostasis (ISTH) major bleeding within 7 days (or up to discharge) following CABG surgery compared between patients with and without postoperative thrombocytopenia. RESULTS This study included 280 patients. Major bleeding occurred in 24.6% of the population, with no difference when stratified by the presence or absence of postoperative thrombocytopenia (27.3% versus 23.8%, p = 0.571). There was no significant difference in hemoglobin fall (13.6% versus 14%, p = 0.948), transfusion requirement (6.1% versus 4.2%, p = 0.531), or critical site bleeding (12.1% versus 7.9%, p = 0.298). CONCLUSION In this single-center analysis of patients who received aspirin within 24 hours of CABG, postoperative thrombocytopenia was not associated with an increase in bleeding.
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Affiliation(s)
- Anne M Rodino
- Department of Pharmacy, 24560Northwestern Memorial Hospital, Chicago, IL, USA
| | - James B Henderson
- Department of Pharmacy, 3065Duke University Hospital, Durham, NC, USA
| | - Kelsey F Dobbins
- Department of Pharmacy, 537791WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Deanna T Rubin
- 15521UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
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Raju SN, Shaw M, Pandey NN, Sharma A, Kumar S. Imaging evaluation using computed tomography after ascending aortic graft repair. Asian Cardiovasc Thorac Ann 2020; 29:132-142. [PMID: 32957798 DOI: 10.1177/0218492320960331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prosthetic aortic graft repair is employed in the management of various conditions such as annuloaortic ectasia, ascending aortic aneurysm, type A aortic dissection, and aortic root abscess. Correct interpretation of post-surgical prosthetic graft complications requires familiarity with the expected normal cross-sectional imaging appearance as well knowledge of additional surgical materials used in the repair, which could influence the imaging appearance. Multiple life-threatening complications of a prosthetic ascending aortic graft can be seen in the aorta and vicinity of the operative field. Complications can arise from involvement of the prosthetic aortic graft per se or secondary involvement of the coronary arteries, mediastinum, and sternotomy site. The optimal imaging protocol using multidetector computed tomography allows accurate interpretation of the expected benign postoperative changes as well as complications associated with the prosthetic graft, and differentiation of true complications from their mimickers. This review focuses on the normal imaging appearance of a prosthetic aortic graft on multidetector computed tomography, and imaging evaluation of multiple post-surgical complications that could arise after repair of the ascending aorta and the aortic valve.
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Affiliation(s)
- Sreenivasa Narayana Raju
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Shaw
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Sharma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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Patel K, Adalti S, Runwal S, Singh R, Ananthanarayanan C, Doshi C, Pandya H. Re‐exploration after off‐pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing. J Card Surg 2020; 35:3062-3069. [DOI: 10.1111/jocs.14986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Kartik Patel
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Sudhir Adalti
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Shreyas Runwal
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Rahul Singh
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | | | - Chirag Doshi
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Himani Pandya
- Department of Research U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
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Saour M, Zeroual N, Aubry E, Blin C, Gaudard P, Colson PH. Blood Loss Kinetics During the First 12 Hours After On-Pump Cardiac Surgical Procedures. Ann Thorac Surg 2020; 111:1308-1315. [PMID: 32896545 DOI: 10.1016/j.athoracsur.2020.06.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/04/2020] [Accepted: 06/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anemia and coagulation management and a restrictive transfusion strategy are key points of blood management in patients undergoing cardiac surgical procedures. However, little consideration has been given to the kinetics of postoperative bleeding. This prospective observational study investigated bleeding kinetics from chest tubes to assess whether it was possible to predict, within the early postoperative hours, major bleeding at 12 postoperative hours. METHODS Adult cardiac surgical patients who were admitted consecutively to the postoperative intensive care unit in a tertiary academic hospital from January to June 2016 were included. Blood volume was collected from the chest drains, and major bleeding was defined as bleeding exceeding the 90th percentile of the volume distribution at 12 postoperative hours. Receiver operating characteristics curve analysis was performed with hourly bleeding thresholds to determine the best predictor of major bleeding. RESULTS In 292 patients, bleeding at 12 postoperative hours ranged from 60 to 2190 mL (median, 350 mL), and 30 patients had major bleeding, with a threshold of 675 mL. Bleeding volume declined logarithmically, 54% [IQR, 45% to 63%] within the first 4 hours. Patients with major bleeding had a higher bleeding volume every hour (P < .004). A good predictive value was observed within the first 2 hours (2.73 mL/kg; receiver operating characteristics area under the curve, 0.87 ± 0.04 [IQR, 0.79 to 0.94]; P< .001). CONCLUSIONS The hourly rate of chest tube blood loss seems to be relevant to predict, within the first postoperative hours after cardiac surgical procedures, major bleeding at 12 postoperative hours. Early detection of blood loss may help to improve a patient's blood conservation strategy because it may prompt preemptive treatments.
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Affiliation(s)
- Marine Saour
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Emmanuelle Aubry
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Cinderella Blin
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; Department of Physiology and Experimental Medicine Heart Muscles, National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Montpellier University, Montpellier, France
| | - Pascal H Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; Institute for Functional Genomics, National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Montpellier University, Montpellier, France.
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32
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Mitigating the Risk: Transfusion or Reoperation for Bleeding After Cardiac Surgery. Ann Thorac Surg 2020; 110:457-463. [DOI: 10.1016/j.athoracsur.2019.10.076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 08/23/2019] [Accepted: 10/01/2019] [Indexed: 11/23/2022]
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Tzoumas A, Giannopoulos S, Charisis N, Texakalidis P, Kokkinidis DG, Zisis SN, Machinis T, Koullias GJ. Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis. Vascular 2020; 28:808-815. [PMID: 32493182 DOI: 10.1177/1708538120929506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable. OBJECTIVE The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes. METHODS This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity. RESULTS Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I2 = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I2 = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I2 = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I2 = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I2 = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I2 = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I2 = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I2 = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I2 = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I2 = 0.0%) after a mean follow-up of 47 months. CONCLUSION The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.
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Affiliation(s)
- Andreas Tzoumas
- Fourth Department of Surgery, Medical School Aristotle University, Thessaloniki, Greece
| | | | | | | | - Damianos G Kokkinidis
- Department of Medicine, 24502Jacobi Medical Center, Albert Einstein College of Medicine New York, NY, USA
| | - Sokratis N Zisis
- Fourth Department of Surgery, 68993National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Theofilos Machinis
- Department of Neurosurgery, 6889Virginia Commonwealth University, Richmond, VA, USA
| | - George J Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, 12301Stony Brook University Hospital, Stony Brook, NY, USA
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Agarwal S, Choi SW, Fletcher SN, Klein AA, Gill R. The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care. Anaesthesia 2020; 76:19-26. [PMID: 32406071 DOI: 10.1111/anae.15070] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 12/11/2022]
Abstract
Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.
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Affiliation(s)
- S Agarwal
- Department of Anaesthesia, Manchester University Hospitals, Manchester, UK
| | - S W Choi
- Department of Anaesthesiology, University of Hong Kong
| | - S N Fletcher
- Departments of Anaesthesia and Critical Care, St George's Hospital, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - R Gill
- Shackleton Department of Anaesthesia, University Hospital Southampton, UK
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Marteinsson SA, Heimisdóttir AA, Axelsson TA, Johannesdottir H, Arnadottir LO, Gardarsdottir HR, Johnsen A, Sigurdsson MI, Helgadottir S, Gudbjartsson T. Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes. SCAND CARDIOVASC J 2020; 54:265-273. [PMID: 32351135 DOI: 10.1080/14017431.2020.1751265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.
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Affiliation(s)
| | | | - Tomas A Axelsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Hera Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Linda O Arnadottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Helga R Gardarsdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Arni Johnsen
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Solveig Helgadottir
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Werner RS, Lipps C, Waldhans S, Künzli A. Blood consumption in total arterial coronary artery bypass grafting. J Cardiothorac Surg 2020; 15:23. [PMID: 31952527 PMCID: PMC6969432 DOI: 10.1186/s13019-020-1053-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Accumulating evidence consistently demonstrates that blood transfusion in cardiac surgery is related to decreased short- and long-term survival. We aimed to evaluate periprocedural blood loss and transfusion rates in elective, isolated total arterial coronary artery bypass grafting (CABG) using exclusively skeletonized bilateral internal mammary arteries (IMAs). Methods We identified 1011 consecutive patients with coronary artery disease who underwent CABG between 1/2007 and 12/2014. Of them, 595 patients who presented preoperative hemoglobin levels >9md/dl and underwent elective, isolated CABG for multi-vessel coronary artery disease were included in the study population. 419 patients (70.4%) received total arterial CABG using skeletonized bilateral IMAs, in 176 patients (29.6%) mixed CABG (single IMA & saphenous vein) was performed. Propensity score adjustment using 16 variables was applied to control for treatment effect. Results In patients undergoing total arterial CABG, heterologous blood transfusion could be avoided in 87.8% of all cases. Propensity score adjusted results showed a significantly lower incidence of erythrocyte concentrate transfusion in patients undergoing total arterial CABG compared to mixed CABG (odds ratio 2.74, 95% confidence interval 1.38–5.43, P = 0.004). There were no statistically significant differences in the rates of thrombocyte concentrate (P = 0.39) and fresh frozen plasma transfusions (P = 0.07). Conclusions In this study, patients who underwent elective, isolated total arterial CABG using exclusively skeletonized bilateral IMAs showed reduced transfusion rates of erythrocyte concentrates compared to mixed CABG using a combination of single IMA and saphenous vein grafts. No evidence for a higher incidence of complications was found with a total arterial approach.
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Affiliation(s)
- Raphael Sven Werner
- Department of Thoracic Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland.
| | - Christoph Lipps
- Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland
| | - Stefan Waldhans
- Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland
| | - Andreas Künzli
- Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland
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Xi Z, Gao Y, Yan Z, Zhou YJ, Liu W. The Prognostic Significance of Different Bleeding Classifications in off-pump coronary artery bypass grafting. BMC Cardiovasc Disord 2020; 20:3. [PMID: 31924163 PMCID: PMC6954587 DOI: 10.1186/s12872-019-01315-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/19/2019] [Indexed: 12/01/2022] Open
Abstract
Background Perioperative bleeding during cardiac surgery are known to make patients susceptible to adverse outcomes and several bleeding classifications have been developed to stratify the severity of bleeding events. Further validation of different classifications was needed. The aim of present study was to validate and explore the prognostic value of different bleeding classifications in patients undergoing off-pump coronary artery bypass grafting (OPCAB). Methods Data on baseline and operative characteristics of 3988 patients who underwent OPCAB in Beijing Anzhen Hospital from February 2008 to December 2014 were available. The primary endpoint was a composite of in-hospital death and nonfatal postoperative myocardial infarction (MI). The secondary endpoint was postoperative acute kidney injury (AKI). We explored the association of major bleeding defined by the European registry of Coronary Artery Bypass Grafting (E-CABG), Universal Definition of Perioperative Bleeding (UDPB), Bleeding Academic Research Consortium (BARC) classification and Study of Platelet Inhibition and Patient Outcomes (PLATO) with primary endpoints by multivariable logistic regression analysis and investigated their significance of adverse event prediction using goodness-of-fit tests of − 2 log likelihood. Results In-hospital mortality was 1.23% (n = 49) and postoperative MI was observed in 4.76% (n = 190) of patients, AKI in 24.69% (n = 985). The incidence of the primary outcome was 5.99% (n = 239). Multivariable logistic regression analysis showed that BARC type 4 (OR = 2.64, 95% CI: 1.66–4.19, P < 0.001), UDPB class 4 (OR = 3.52, 95% CI: 2.05–6.02, P < 0.001) and E-CABG class 2–3 (class 2: OR = 2.24, 95% CI: 1.36–3.70, P = 0.001; class 3: OR = 12.65, 95% CI: 2.74–18.43, P = 0.002) bleeding but not PLATO bleeding were associated with an increased risk of in-hospital death and postoperative MI. Major bleeding defined by all the four classifications mentioned above was an independent risk factor of AKI after surgery. Inclusion of major bleeding defined by these four classifications improved the predictive performance of the multivariable model with baseline characteristics. Conclusions Bleeding assessed by BARC, E-CABG and UDPB classifications were significantly associated with poorer immediate outcomes. These classifications seemed to be valuable tool in the assessment of prognostic effect of perioperative bleeding.
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Affiliation(s)
- Ziwei Xi
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yanan Gao
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Zhenxian Yan
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yu-Jie Zhou
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Wei Liu
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China.
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Mazur P, Litwinowicz R, Krzych Ł, Bochenek M, Wasilewski G, Hymczak H, Bartuś K, Filip G, Przybylski R, Kapelak B. Absence of perioperative excessive bleeding in on-pump coronary artery bypass grafting cases performed by residents. Interact Cardiovasc Thorac Surg 2019; 29:836-843. [PMID: 31435666 DOI: 10.1093/icvts/ivz195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES On-pump coronary artery bypass grafting (CABG) is associated with elevated bleeding risk. Our aim was to evaluate the role of surgical experience in postoperative blood loss. METHODS A propensity score-matched analysis was employed to compare on-pump CABG patients operated on by residents and specialists. End points included drainage volume and bleeding severity, as assessed by the Universal Definition of Perioperative Bleeding in cardiac surgery and E-CABG scale. RESULTS A total of 212 matched pairs (c-statistics 0.693) were selected from patients operated on by residents (n = 294) and specialists (n = 4394) between October 2012 and May 2018. Patients did not differ in bleeding risk. There were no statistically significant differences in postoperative 6-, 12- and 24-h drainages between subjects operated on by residents and specialists, and there was no between-group difference in rethoracotomy or transfusion rate. There were no differences in Universal Definition of Perioperative Bleeding or E-CABG grades. In June 2018, after a median follow-up of 2.8 years (range 0.1-5.7 years), the overall survival was 94%, with no differences between the patients operated on by residents (95%) and specialists (92%) (P = 0.27). CONCLUSIONS Patients undergoing on-pump CABG, when operated on by a resident, are not exposed to an elevated bleeding risk, as compared with patients operated on by experienced surgeons.
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Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Łukasz Krzych
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Bochenek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Wasilewski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Hubert Hymczak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Filip
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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Adam EH, Meier J, Klee B, Zacharowski K, Meybohm P, Weber CF, Pape A. Factor XIII activity in patients requiring surgical re-exploration for bleeding after elective cardiac surgery - A prospective case control study. J Crit Care 2019; 56:18-25. [PMID: 31805464 DOI: 10.1016/j.jcrc.2019.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/05/2019] [Accepted: 11/15/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Surgical re-exploration due to postoperative bleeding is associated with increased morbidity and mortality. The aim of our study was to assess a potential association between the level of postoperative FXIII activity and need for re-exploration due to bleeding in patients undergoing cardiothoracic surgery. MATERIALS AND METHODS In our prospective single center observational cohort study, we enrolled patients who underwent elective cardiothoracic surgery. Patients who required re-exploration (RE group) were matched to patients from the study population (non-RE group). RESULTS The study included 64 patients, out of a cohort of 678 patients, of whom 32 required surgical re-exploration due to bleeding within the first 24 h. Between patients of the RE and non-RE group, a significantly reduced FXIII activity was observed postoperatively (59.0 vs 71.1; p = .014). Multivariable analysis revealed reduced FXIII activity (p = .048) as a parameter independently associated with surgical re-exploration. Further, reduced FXIII activity (p = .037) and surgical re-exploration (p = .01) were significantly associated with increased 30 day mortality. In multivariable analysis re-exploration was independently associated with increased risk of 30 day mortality (p = .004, HR 9.68). CONCLUSIONS Reduced postoperative FXIII activity may be associated with the need for surgical re-exploration. Postoperative assessment of FXIII activity should therefore be considered in patients undergoing elective cardiothoracic surgery.
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Affiliation(s)
- Elisabeth H Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Jens Meier
- Department of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4021 Linz, Austria.
| | - Bernd Klee
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Christian F Weber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany; Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstr. 14, 22043 Hamburg, Germany.
| | - Andreas Pape
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
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Nwafor IA, Eze JC. Management of bleeding and blood transfusion in open cardiac surgery in a developing country: five-years institutional experience. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04904-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Knapik P, Knapik M, Zembala MO, Przybyłowski P, Nadziakiewicz P, Hrapkowicz T, Cieśla D, Deja M, Suwalski P, Jasiński M, Tobota Z, Maruszewski BJ, Zembala M, Anisimowicz L, Biederman A, Borkowski D, Brykczyński M, Bugajski P, Cholewiński P, Cichoń R, Cisowski M, Deja M, Dziatkowiak A, Gryszko LA, Gburek T, Haponiuk I, Hendzel P, Hirnle T, Jabłonka S, Jarmoszewicz K, Jasiński M, Jaszewski R, Jemielity M, Kalawski R, Kapelak B, Kaperczak J, Karolczak MA, Krejca M, Kustrzycki W, Kuśmierczyk M, Kwinecki P, Maruszewski B, Missima M, Ogorzeja JJMW, Pająk J, Pawliszak W, Pietrzyk E, Religa G, Rogowski J, Różański J, Sadowski J, Sharma G, Skalski J, Skiba J, Stążka J, Stępiński P, Suwalski K, Suwalski P, Tobota Z, Tułecki Ł, Widenka K, Wojtalik M, Woś S, Zembala M, Żelazny P. In-hospital and mid-term outcomes in patients reoperated on due to bleeding following coronary artery surgery (from the KROK Registry). Interact Cardiovasc Thorac Surg 2019; 29:237–243. [PMID: 30968119 DOI: 10.1093/icvts/ivz089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Surgical re-exploration due to postoperative bleeding that follows coronary artery surgery is associated with significant morbidity and mortality. The aim of this study was to assess a relationship between re-exploration, major postoperative complications, in-hospital mortality and mid-term outcomes in patients following coronary surgery, on the basis of nationwide registry data. METHODS We identified all consecutive patients enrolled in Polish National Registry of Cardiac Surgical Procedures (KROK Registry) who underwent isolated coronary surgery between January 2012 and December 2014. Preoperative data, major postoperative complications, hospital mortality and mid-term all-cause mortality were, respectively, analysed. Comparisons were performed in all patients, low-risk patients (EuroSCORE II < 2%, males, aged 60-70 years) and propensity-matched patients. The starting point for follow-up was the date of hospital discharge. RESULTS Among 41 353 analysed patients, 1406 (3.4%) underwent re-exploration. Reoperated patients had more comorbidities, more frequent major postoperative complications, higher in-hospital mortality (13.2% vs 1.8%, P < 0.001) and higher mid-term mortality in survivors (P < 0.001). In the low-risk population, 3.0% of patients underwent re-exploration. Reoperated low-risk patients and propensity-matched patients also had more frequent major postoperative complications and higher in-hospital mortality, but mid-term mortality in survivors was similar. In a multivariable analysis, re-exploration was an independent predictor of death and all major postoperative complications. CONCLUSIONS Surgical re-exploration due to postoperative bleeding following coronary artery surgery carries a high risk of perioperative mortality and is linked to major postoperative complications. Among patients who survive to hospital discharge, mid-term mortality is associated primarily with preoperative comorbidities.
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Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Małgorzata Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Michał O Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Piotr Przybyłowski
- Division of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Centre for Heart Diseases, Zabrze, Poland.,First Department of General Surgery, Jagiellonian University, Medical College, Cracow, Poland
| | - Paweł Nadziakiewicz
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Upper-Silesian Medical Centre, Medical University of Silesia, Katowice, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marek Jasiński
- Department of Cardiac Surgery, University Teaching Hospital, Wrocław, Poland
| | - Zdzisław Tobota
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan J Maruszewski
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
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Habib AM, Calafiore AM, Cargoni M, Foschi M, Di Mauro M. Recombinant activated factor VII is associated with postoperative thromboembolic adverse events in bleeding after coronary surgery. Interact Cardiovasc Thorac Surg 2019; 27:350-356. [PMID: 29566162 DOI: 10.1093/icvts/ivy067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 02/07/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the impact of recombinant activated factor VII (rFVIIa) administration on thromboembolic adverse events (TAEs) in coronary artery bypass grafting (CABG) surgery patients showing postoperative bleeding. METHODS From January 2004 to May 2015, 180 CABG surgery patients with postoperative bleeding were included in the study. All patients were managed conservatively and 81 (45%) also received rFVIIa. RESULTS Ten patients developed new TAEs (5.6%), 15 (8.3%) were re-explored, 4 (2.2%) had postoperative dialysis and 6 (3.3%) died by day 30 postoperation. Among those with TAEs, 7 experienced cerebrovascular accidents, 2 had myocardial infarction and 1 had pulmonary embolism. A multivariable regression model confirmed rFVIIa as the only independent factor associated with the development of TAEs (odds ratio 6.19, 95% confidence interval 1.197-31.996; P = 0.0296). Fifteen (8.3%) patients were re-explored for bleeding according to our management protocol. No variables to predict the need for re-exploration were identified by the regression model. Chest tube output was statistically significantly lower in patients who received rFVIIa from 3 h [1.9 (Q1-Q3 1.7-2.1) ml/kg/h vs 3.2 (Q1-Q3 3-3.4) ml/kg/h, P = 0.000] through to 12 h after admission [0.6 (Q1-Q3 0.5-0.6) ml/kg/h vs 0.7 (Q1-Q3 0.6-0.9) ml/kg/h, P = 0.000]. CONCLUSIONS rFVIIa for the treatment of post-CABG bleeding resulted in increased incidence of TAEs in spite of rapid control of bleeding. Hence, rFVIIa should only be used for selected patients and with extreme caution.
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Affiliation(s)
- Aly Makram Habib
- Department of Cardiac Surgical Intensive Care Unit (CSICU), Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Adult Cardiac (Surgical) Intensive Care Unit (ACICU), Intensive Care Department, Prince Sultan Cardiac Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.,Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Marco Cargoni
- Department of Anesthesiology-Cardiac Surgical Intensive Care Unit (CSICU) and Cardiac Surgery, SS Annunziata Hospital, Chieti, Italy
| | - Massimiliano Foschi
- Department of Anesthesiology-Cardiac Surgical Intensive Care Unit (CSICU) and Cardiac Surgery, SS Annunziata Hospital, Chieti, Italy
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Al-Attar N, Johnston S, Jamous N, Mistry S, Ghosh E, Gangoli G, Danker W, Etter K, Ammann E. Impact of bleeding complications on length of stay and critical care utilization in cardiac surgery patients in England. J Cardiothorac Surg 2019; 14:64. [PMID: 30940172 PMCID: PMC6444533 DOI: 10.1186/s13019-019-0881-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background Bleeding is a significant complication in cardiac surgery and is associated with substantial morbidity and mortality. This study evaluated the impact of bleeding on length of stay (LOS) and critical care utilization in a nationwide sample of cardiac surgery patients treated at English hospitals. Methods Retrospective, observational cohort study using linked English Hospital Episode Statistics (HES) and Clinical Practice Research Datalink (CPRD) records for a nationwide sample of patients aged ≥18 years who underwent coronary artery bypass graft (CABG), valve repair/replacement, or aortic operations from January 2010 through February 2016. The primary independent variables were in-hospital bleeding complications and reoperation for bleeding before discharge. Generalized linear models were used to quantify the adjusted mean incremental difference [MID] in post-procedure LOS and critical care days associated with bleeding complications, independent of measured baseline characteristics. Results The study included 7774 cardiac surgery patients (3963 CABG; 2363 valve replacement/repair; 160 aortic procedures; 1288 multiple procedures, primarily CABG+valve). Mean LOS was 10.7d, including a mean of 4.2d in critical care. Incidences of in-hospital bleeding complications and reoperation for bleeding were 6.7 and 0.3%, respectively. Patients with bleeding had longer LOS (MID: 3.1d; p < 0.0001) and spent more days in critical care (MID: 2.4d; p < 0.0001). Reoperation for bleeding was associated with larger increases in LOS (MID = 4.0d; p = 0.002) and days in critical care (MID = 3.2d; p = 0.001). Conclusions Among English cardiac surgery patients, in-hospital bleeding complications were associated with substantial increases in healthcare utilization. Increased use of evidence-based strategies to prevent and manage bleeding may reduce the clinical and economic burden associated with bleeding complications in cardiac surgery. Electronic supplementary material The online version of this article (10.1186/s13019-019-0881-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nawwar Al-Attar
- Department of Cardiac Surgery, Golden Jubilee National Hospital, University of Glasgow, Agamemnon St, Clydebank G81 4DY, Glasgow, UK.
| | - Stephen Johnston
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Nadine Jamous
- Health Economics & Market Access, Johnson & Johnson Medical Ltd, Berkshire, UK
| | - Sameer Mistry
- Medical Affairs, Johnson & Johnson Medical Ltd, Berkshire, UK
| | | | - Gaurav Gangoli
- Health Economics & Market Access, Ethicon, Somerville, NJ, USA
| | - Walter Danker
- Health Economics & Market Access, Ethicon, Somerville, NJ, USA
| | - Katherine Etter
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Eric Ammann
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
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Development and validation of a measurement system for continuously monitoring postoperative reservoir levels. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 42:611-617. [PMID: 30868479 DOI: 10.1007/s13246-019-00746-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
Following cardiac surgical procedures, multiple drainage systems remain in place inside the patient's chest to prevent the development of pericardial effusion or pneumothorax. Therefore, postoperative bleeding must be diligently observed. Currently, observation of the exudate rate is performed through periodical visual inspection of the reservoir. To improve postoperative monitoring, a measurement system based on load cells was developed to automatically detect bleeding rates. A reservoir retaining bracket was instrumented with a load cell. The signal was digitized by a microcontroller and then processed and displayed on customized software written in LabView. In cases where bleeding rates reach critical levels, the device will automatically sound an alarm. Additionally, the bleeding rate is displayed on the screen with the status of the alarm, as well as the fluid level of the reservoir. These data are all logged to a file. The measurement system has been validated for gain stability and drift, as well as for sensor accuracy, with different in vitro examinations. Additionally, performance of the measurement device was tested in a clinical pilot study on patients recovering from cardiac surgical procedures. The in vitro investigation showed that the monitoring device had excellent gain and drift stability, as well as sensor accuracy, with a resolution of 2.6 mL/h for the bleeding rate. During the clinical examination, bleeding rates of all patients were correctly measured. Continuously recording drainage volume using the developed system was comparable to manual measurements performed every 30 min by a nurse. Implementation of continuous digital measurements could improve patient safety and reduce the workload of medical professionals working in intensive care units.
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Hobbs RD, Paone G, D'Agostino RS, Jacobs JP, McDonald DE, Prager RL, Shahian DM. Myocardial revascularization: the evolution of the STS database and quality measurement for improvement. Indian J Thorac Cardiovasc Surg 2018; 34:222-229. [PMID: 33060942 DOI: 10.1007/s12055-018-0726-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 01/03/2023] Open
Abstract
The Society of Thoracic Surgeons (STS) is a not-for-profit organization dedicated to helping clinicians and researchers provide optimal outcomes for patients undergoing heart, lung, and esophageal surgery. The organization was founded in 1964 and has grown to now include over 7300 members in over 90 countries. The STS created a national database that collects detailed clinical information on patients undergoing adult cardiac, pediatric and congenital cardiac, and general thoracic operations. The data collected are used to produce risk-adjusted, nationally benchmarked performance assessments and feedback; facilitate voluntary public reporting; support quality initiatives; develop evidence-based guidelines; monitor long-term clinical outcomes; track device performance; and promote high-quality research collaboratives.
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Affiliation(s)
| | - Gaetano Paone
- Division of Cardiac Surgery, Henry Ford Hospital, Detroit, MI USA
| | | | - Jeffrey Phillip Jacobs
- The Congenital Heart Institute of Florida (CHIF), All Children's Hospital, University of South Florida College of Medicine, Saint Petersburg, FL USA
- The Congenital Heart Institute of Florida (CHIF), All Children's Hospital, University of South Florida College of Medicine, Tampa, FL USA
| | | | | | - David Michael Shahian
- Center for Quality and Safety and Department of Surgery, Massachusetts General Hospital, Boston, MA USA
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Poststernotomy Complications: A Multimodal Review of Normal and Abnormal Postoperative Imaging Findings. AJR Am J Roentgenol 2018; 211:1194-1205. [DOI: 10.2214/ajr.18.19782] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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47
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Coulson TG, Mullany DV, Reid CM, Bailey M, Pilcher D. Measuring the quality of perioperative care in cardiac surgery. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:11-19. [PMID: 28927188 DOI: 10.1093/ehjqcco/qcw027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Indexed: 11/13/2022]
Abstract
Quality of care is of increasing importance in health and surgical care. In order to maintain and improve quality, we must be able to measure it and identify variation. In this narrative review, we aim to identify measures used in the assessment of quality of care in cardiac surgery and to evaluate their utility. The electronic databases Pubmed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and CINAHL were searched for original published studies using the terms 'cardiac surgery' and 'quality or outcome or process or structure' as either keywords in the title or text or MeSH terms. Secondary searches and identification of references from original articles were carried out. We found a total of 54 original articles evaluating measurements of quality. While structure, process, and outcome indicators remain the mainstay of quality measurement, new and innovative methods of risk assessment have improved reliability and discrimination. Continuous assessment provides a promising method of both maintaining and improving quality of care. Future studies should focus on long-term and patient-centred outcomes, such as quality-of-life measures.
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Affiliation(s)
- Tim G Coulson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel V Mullany
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Bailey
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, 55 Commercial Rd, Melbourne, Victoria 3004, Australia.,ANZICS Centre for Outcome and Resource Evaluation, Ievers Terrace, Carlton, Melbourne, Victoria, Australia
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Pereira KMFSM, de Assis CS, Cintra HNWL, Ferretti-Rebustini REL, Püschel VAA, Santana-Santos E, Rodrigues ARB, de Oliveira LB. Factors associated with the increased bleeding in the postoperative period of cardiac surgery: A cohort study. J Clin Nurs 2018; 28:850-861. [PMID: 30184272 DOI: 10.1111/jocn.14670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
AIMS AND OBJECTIVES To identify factors associated with the increased bleeding in patients during the postoperative period after cardiac surgery. BACKGROUND Bleeding is among the most frequent complications that occur in the postoperative period after cardiac surgery, representing one of the major factors in morbidity and mortality. Understanding the factors associated with the increased bleeding may allow nurses to anticipate and prioritise care, thus reducing the mortality associated with this complication. DESIGN Prospective cohort study. METHODS Adult patients in a cardiac hospital who were in the postoperative period following cardiac surgery were included. Factors associated with the increased bleeding were investigated by means of linear regression, considering time intervals of 6 and 12 hr. RESULTS The sample comprised 391 participants. The factors associated with the increased bleeding in the first 6 hr were male sex, body mass index, cardiopulmonary bypass duration, anoxia duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative period. Predictors in the first 12 hr were body mass index, cardiopulmonary bypass duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative. CONCLUSIONS This study identified factors associated with the increased postoperative bleeding from cardiac surgery that have not been reported in previous studies. The nurse is important in the vigilance, evaluation and registry of chest tube drainage and modifiable factors associated with the increased bleeding, such as metabolic acidosis and postoperative heart rate, and in discussions with the multiprofessional team. RELEVANCE TO CLINICAL PRACTICE Knowledge of the factors associated with the increased bleeding is critical for nurses so they can provide prophylactic interventions and early postoperative treatment when needed.
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Affiliation(s)
- Kárla M F S M Pereira
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Caroline S de Assis
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Haulcionne N W L Cintra
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Vilanice A A Püschel
- Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de Sao Paulo, SP, BR
| | | | - Adriano Rogério B Rodrigues
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Larissa B de Oliveira
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.,Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de Sao Paulo, SP, BR.,Nursing Department, Sociedade de Cardiologia do Estado de Sao Paulo, SP, BR
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Korpallová B, Samoš M, Bolek T, Škorňová I, Kovář F, Kubisz P, Staško J, Mokáň M. Role of Thromboelastography and Rotational Thromboelastometry in the Management of Cardiovascular Diseases. Clin Appl Thromb Hemost 2018; 24:1199-1207. [PMID: 30041546 PMCID: PMC6714776 DOI: 10.1177/1076029618790092] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The monitoring of coagulation by viscoelastometric methods—thromboelastography and rotational thromboelastometry—may detect the contributions of cellular and plasma components of hemostasis. These methods might overcome some of the serious limitations of conventional laboratory tests. Viscoelastic testing can be repeatedly performed during and after surgery and thus provides a dynamic picture of the coagulation process during these periods. Several experiences with the use of these methods in cardiovascular surgery have been reported, but there is perspective for more frequent use of these assays in the assessment of platelet response to antiplatelet therapy and in the assessment of coagulation in patients on long-term dabigatran therapy. This article reviews the current role and future perspectives of thromboelastography and thromboelastometry in the management of cardiovascular diseases.
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Affiliation(s)
- Barbora Korpallová
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Tomáš Bolek
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ingrid Škorňová
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - František Kovář
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ján Staško
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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Hsu PS, Yang HY, Chen JL, Tsai YT, Lin CY, Ke HY, Lin YC, Tsai CS. The implication of seniority of supervising attending surgeon on the reexploration rate following elective coronary artery bypass grafting. J Formos Med Assoc 2018; 118:354-361. [PMID: 29936106 DOI: 10.1016/j.jfma.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/19/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND AIMS During coronary artery bypass graft (CABG) surgery, the residual hemostasis procedures, from weaning cardiopulmonary bypass to closing sternotomy, are always completed by residents and supervised by attending surgeons. We want to evaluate the teaching effectiveness for residents under the supervision of attending surgeons with different levels of seniority. MATERIALS AND METHODS Between January 1st 2001 and December 31st 2010, 2279 consecutive CABG surgeries were performed in our medical center. In total, 83 patients underwent a reexploration for postoperative bleeding. All causes of bleeding were identified and recorded. Competent attending surgeons were defined as having >3 years' experience and young attending surgeons with ≦3 years' experience. We compared the reexploration rate and aimed to identify the common sources of bleeding by the two groups. We also assessed the impact of attending experience on the outcomes and major complications after reexploration. RESULTS There were 36 surgical bleeding and 17 non-surgical bleeding in the young group and 16 surgical bleeding and 14 non-surgical bleeding in the competent group. The young group experienced more mediastinal drainage before a reexploration and a longer time interval to a reexploration. However, both are without statistical significance. Furthermore, the young group has a significant longer hospital stay. The most common intra-pericardium surgical bleeding included two-stage cannulation, side branch of the left internal mammary artery (LIMA), and side branch of vein grafts. The most common extra-pericardium surgical bleeding included a puncture hole by sternal wires, LIMA bed, and fragile sternum. CONCLUSION Young attending surgeons indeed had both higher incidence of reexploration and surgical bleeding after a CABG. However, the supervisor experience only impacted hospital stay, not major complications or mortality after a reexploration. This might imply the competent attending surgeons provide higher teaching effectiveness for the hemostasis procedure after CABG.
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Affiliation(s)
- Po-Shun Hsu
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsiang-Yu Yang
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jia-Lin Chen
- Department of Anesthesia, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ting Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yuan Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hong-Yan Ke
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Chang Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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