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Kemberi M, Urgesi E, Ng JY, Patel K, Khanji MY, Awad WI. Outcomes of Patients Presenting With Non-ST Elevation Myocardial Infarction Who Underwent Surgical Revascularization. Am J Cardiol 2024; 223:165-173. [PMID: 38777209 DOI: 10.1016/j.amjcard.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/23/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalization across Europe. This study evaluates the in-hospital and mid-term outcomes of patients who underwent coronary artery bypass graft (CABG) after NSTEMI. A retrospective analysis of all cases who underwent isolated CABG after NSTEMI from September 2017 to September 2022 at our center. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modeling. Kaplan-Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1,011 patients (median age 64 [56 to 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1,011 patients). Those who died were more likely to be New York Heart Association class III/IV, have left ventricular ejection fraction <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, preoperative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modeling revealed new postoperative stroke (odds ratio 22.0, 95% confidence interval 3.6 to 135.5, p = 0.001), preoperative IABP use (11.4; 2.4 to 53.7, p = 0.002), new hemodialysis (9.6; 2.7 to 34.7, p <0.001), PVD (5.6; 1.6 to 20.0, p = 0.008), and poor mobility (odds ratio 4.8, 95% confidence interval 1.3 to 18.2, p = 0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, preoperative IABP use, new hemodialysis, PVD, and poor mobility are independent predictors of mortality in patients with NSTEMI who underwent isolated CABG.
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Affiliation(s)
- Marsioleda Kemberi
- Department of Cardiothoracic Surgery, Barts and the London Medical School, London, United Kingdom
| | - Eduardo Urgesi
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Jing Yong Ng
- Department of Cardiothoracic Surgery, Barts and the London Medical School, London, United Kingdom
| | - Kush Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | | | - Wael I Awad
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; William Harvey Research Institute, QMUL, London, United Kingdom.
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Fiameni R, Lucchelli M, Novelli C, Salice V, Orsenigo F, Gomarasca M, MoroSalihovic B, Mondin F, Mistraletti G, Beverina I. Impact of introduction of a goal directed transfusion strategy in a patient blood management program: A single cardiac surgery centre experience. Transfus Med 2024. [PMID: 38945994 DOI: 10.1111/tme.13063] [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: 10/24/2023] [Revised: 05/16/2024] [Accepted: 06/18/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The aim of this retrospective and observational study was to analyse the impact of the introduction of a goal directed transfusion (GDT) strategy based on a viscoelastic test (ROTEM®) and specific procoagulant products in a patient blood management (PBM) Program on blood product use and perioperative bleeding in a single cardiac surgery centre. STUDY DESIGN AND METHODS Patient population underwent cardiac surgery from 2011 to 2021 was divided in two groups based on PBM protocol used (G#11-14, years 2011-2014, G#15-21, years 2015-2021) and compared for the following variables: intraoperative and postoperative transfusions of packed red blood cell and any procoagulant products, postoperative drain blood loss volume and rate of re-exploration surgery. The second program was defined after the introduction of a GDT protocol based on viscoelastic tests and specific procoagulant products. RESULTS After the introduction of a GDT protocol, about 80% less amongst patients were transfused with fresh frozen plasma and any procoagulant product (p < 0.001 for both phases). Moreover, similar results were obtained with PRBC transfusions (p < 0.001) and drain blood loss volume (p = 0.006) in the postoperative phase. The main factors affecting the use of any procoagulant and PBRC transfusion in the multivariate logistic regression analysis was Group (2 versus 1, OR 0.207, p < 0.001) and preoperative haemoglobin (OR 0.728, p < 0.001), respectively. DISCUSSION In our experience, a GDT strategy for the diagnosis and treatment of the coagulopathy in patients undergone cardiac surgery led to a significant reduction in bleeding and transfusion.
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Affiliation(s)
- Riccardo Fiameni
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Matteo Lucchelli
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Chiara Novelli
- S.C. Immunoematologia e Centro Trasfusionale, ASST Ovest Milanese, Legnano, Italy
| | - Valentina Salice
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Francesca Orsenigo
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Mattia Gomarasca
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | | | - Federico Mondin
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Giovanni Mistraletti
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Italy
| | - Ivo Beverina
- S.C. Immunoematologia e Centro Trasfusionale, ASST Ovest Milanese, Legnano, Italy
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Monaco F, Guarracino F, Vendramin I, Lei C, Zhang H, Lomivorotov V, Osinsky R, Efremov S, Gürcü ME, Mazzeffi M, Pasyuga V, Kotani Y, Biondi-Zoccai G, D'Ascenzo F, Romagnoli E, Nigro Neto C, Do Nascimento VTNDS, Ti LK, Lorsomradee S, Farag A, Bukamal N, Brizzi G, Lobreglio R, Belletti A, Arangino C, Paternoster G, Bonizzoni MA, Tucciariello MT, Kroeller D, Di Prima AL, Mantovani LF, Ajello V, Gerli C, Porta S, Ferrod F, Giardina G, Santonocito C, Ranucci M, Lembo R, Pisano A, Morselli F, Nakhnoukh C, Oriani A, Pieri M, Scandroglio AM, Kırali K, Likhvantsev V, Longhini F, Yavorovskiy A, Bellomo R, Landoni G, Zangrillo A. Acute normovolemic hemodilution in cardiac surgery: rationale and design of a multicenter randomized trial. Contemp Clin Trials 2024; 143:107605. [PMID: 38866095 DOI: 10.1016/j.cct.2024.107605] [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: 01/31/2024] [Revised: 05/12/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Igor Vendramin
- Division of Cardiac Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; Department of Medicine, University of Udine, Udine, Italy
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Vladimir Lomivorotov
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia; Penn State Milton S. Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine, Hershey, PA, USA
| | - Roman Osinsky
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia
| | - Sergey Efremov
- Saint Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Mustafa Emre Gürcü
- Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Vadim Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russian Federation
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | | | - Fabrizio D'Ascenzo
- Cardiovascular and Thoracic Department, A.O.U. Città della Salute e della Scienza, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via Pineta Sacchetti, 217, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Campus di Roma, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | | | | | | | - Ahmed Farag
- King Abdullah Medical City - Holy Capital (KAMC-HC), Makkah, Saudi Arabia
| | - Nazar Bukamal
- Cardiothoracic ICU and Anesthesia Department, Mohammed Bin Khalifa Specialist Cardiac Center, Awali 183261, Bahrain
| | - Giulia Brizzi
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Arangino
- Department of Cardiothoracic Anesthesia and Intensive Care, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Gianluca Paternoster
- Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Matteo Aldo Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Daniel Kroeller
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Valentina Ajello
- Department of Cardio Thoracic anesthesia and Intensive Care, Hospital Tor Vergata Roma, Italy
| | - Chiara Gerli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Porta
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Federica Ferrod
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Giuseppe Giardina
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Santonocito
- Anaesthesia and Intensive Care Medicine III, Policlinico University Hospital, Catania, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Pisano
- Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy
| | - Federica Morselli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Nakhnoukh
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kaan Kırali
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valery Likhvantsev
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russian Federation; Department of Anesthesiology and Resuscitation, First Moscow State Medical University, Moscow, Russian Federation
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy
| | - Andrey Yavorovskiy
- I.M. Sechenov First Moscow State Medical University, Ministry of Public Health of Russia, Moscow, Russia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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4
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Shou BL, Zhou AL, Ong CS, Alejo DE, DiNatale JM, Larson EL, Lawton JS, Schena S. Impact of intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00967-4. [PMID: 37839660 DOI: 10.1016/j.jtcvs.2023.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/06/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE Risk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration. METHODS We retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding. RESULTS Of 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P < .001) and 30-day mortality (14% vs 2%, P < .001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after ∼6 L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration. CONCLUSIONS We found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Alice L Zhou
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Chin Siang Ong
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | - Diane E Alejo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Joseph M DiNatale
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Emily L Larson
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Stefano Schena
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
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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: 2] [Impact Index Per Article: 2.0] [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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Jahangirifard A, Mirtajani SB, Madadi F. Effect of Desmopressin on Bleeding After Heart Surgeries: A Narrative Review. Anesth Pain Med 2023; 13:e133894. [PMID: 37645010 PMCID: PMC10461384 DOI: 10.5812/aapm-133894] [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: 11/30/2022] [Revised: 02/01/2023] [Accepted: 02/12/2023] [Indexed: 08/31/2023] Open
Abstract
Desmopressin is an analog of the antidiuretic hormone (vasopressin), which causes anticoagulant activity by increasing plasma factor 8. The use of desmopressin dates back to 1977, when this hormone was used to prevent bleeding during tooth extraction and surgery in patients with hemophilia A and von Willebrand disease. After that, this hormone was expanded to prevent bleeding in congenital defects and conditions such as chronic kidney and liver failure. Also, this hormone is used to prevent bleeding in major surgeries such as heart surgery, where the patient loses much blood and needs a blood transfusion. Considering the importance of desmopressin in bleeding control, the present study was conducted to investigate the possible effect of this hormone in heart surgery.
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Affiliation(s)
- Alireza Jahangirifard
- Lung Transplant Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Bashir Mirtajani
- Lung Transplant Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Firoozeh Madadi
- Department of Anesthesiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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7
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Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis. Gen Thorac Cardiovasc Surg 2023; 71:323-330. [PMID: 36884106 DOI: 10.1007/s11748-023-01923-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Cardiac surgical procedures are associated with a high incidence of periprocedural blood loss and blood transfusion. Although both may be associated with a range of postoperative complications there is disagreement on the impact of blood transfusion on long-term mortality. This study aims to provide a comprehensive review of the published outcomes of perioperative blood transfusion, examined as a whole and by index procedure. METHODS A systematic review of perioperative blood transfusion cardiac surgical patients was conducted. Outcomes related to blood transfusion were analysed in a meta-analysis and aggregate survival data were derived to examine long-term survival. RESULTS Thirty-nine studies with 180,074 patients were identified, the majority (61.2%) undergoing coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR 3.87, p < 0.001). After a median of 6.4 years (range 1-15), mortality remained significantly higher for those who received a perioperative transfusion (OR 2.01, p < 0.001). Pooled hazard ratio for long-term mortality similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies. CONCLUSIONS Perioperative red blood transfusion appears to be associated with a significant reduction in long-term survival for patients after cardiac surgery. Strategies such as preoperative optimisation, intraoperative blood conservation, judicious use of postoperative transfusions, and professional development into minimally invasive techniques should be utilised where appropriate to minimise the need for perioperative transfusions.
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8
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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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9
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Alzahrani A, Alkofide H, Joharji H, Korayem GB, Aljohani S, Alshareef H, AlFaifi M, Alalawi H, Sulaiman KA. Evaluation of the Safety and Effectiveness of Topical Intrapleural Application of Tranexamic Acid in Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Appl Thromb Hemost 2023; 29:10760296231218215. [PMID: 38115686 PMCID: PMC10734325 DOI: 10.1177/10760296231218215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVES Bleeding remains a common complication post-thoracic surgery. Although intravenous tranexamic acid (TXA) has been shown to decrease blood loss, its use has been associated with adverse effects. Accordingly, topical TXA has been proposed as an alternative to reduce bleeding with fewer systemic complications. METHODS We searched Medline, Embase, and Cochrane Central databases for randomized controlled trials (RCTs) comparing topical TXA versus control (i.e., placebo) in patients undergoing thoracic procedures. The primary outcome was total postoperative blood loss at 24 hours. Secondary outcomes included were the number of red blood cell (RBC) transfusions, and hospital length of stay (LOS). Meta-analyses were pooled using mean difference with inverse-variance weighting and random-effects. RESULTS Out of the 575 unique studies that were screened, we identified three randomized controlled trials (RCTs) involving 399 patients. Out of the three RCTs analyzed, two studies, accounting for 67% of the total, were found to have a low risk of bias. The primary outcome of 24-h post-operative blood loss was significantly lower in patients who received TXA (mean difference [MD] -93.6 ml, 95% CI -121.8 to -65.4 ml, I2 = 45%). In addition, the need for RBC transfusion was significantly lower in the topical TXA group compared to control (MD -0.5 units, 95% CI -0.8 to -0.3 units, I2 = 60%). However, there was no significant difference in the hospital length of stay (LOS) (MD -0.3 days, 95% CI -0.9 to 0.4 days, I2 = 0%). These results remained consistent after several sensitivity analyses. The use of topical intrapleural tranexamic acid has also been found to be safe without any significant safety concerns. CONCLUSION Topical intrapleural TXA reduces blood loss and the need for blood transfusions during thoracic surgery. In addition, there is no evidence of the increased safety concerns associated with its use. Larger trials are necessary to validate these findings and evaluate the safety and efficacy of different dosages.
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Affiliation(s)
- Amer Alzahrani
- Division of Thoracic Surgery, Department of Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of Excellence, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Drug Regulation Research Affairs Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hala Joharji
- King Faisal Specialist Hospital and Research Centre Organ Transplant Center of Excellence, Riyadh, Saudi Arabia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sarah Aljohani
- Department of Pharmaceutical Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Hanan Alshareef
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Mashael AlFaifi
- Pharmaceutical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Hassan Alalawi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
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10
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Li J, Wu Q, Tang M, Shen Y, Qiu Z, Chen X, Chen X, Chen L. Preoperative clinical application of human fibrinogen in patients with acute Stanford type A aortic dissection: A single-center retrospective study. J Card Surg 2022; 37:3159-3165. [PMID: 35864807 DOI: 10.1111/jocs.16759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the perioperative clinical efficacy of preoperative human fibrinogen treatment in patients with acute Stanford type A aortic dissection (ATAAD). METHODS Data of 159 patients with ATAAD who underwent emergency surgical treatment in our hospital from January 2019 to December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether human fibrinogen was administered before surgery: patients in group A received fibrinogen before surgery, while those in group B did not. The preoperative clinical data, surgical data, postoperative data, complications related to the coagulation function, and mortality of the two groups were compared and analyzed. RESULTS The in-hospital mortality was similar in the two groups (2.9% vs. 9.3%, p = .122). However, group A had a significantly shorter operation time (279.24 ± 39.03 vs. 298.24 ± 45.90, p = .008), lower intraoperative blood loss (240.48 ± 96.75 vs. 353.70 ± 189.80, p < .001), and reduced intraoperative transfusion requirement of red blood cells (2.61 ± 1.18 vs. 6.05 ± 1.86, p < .001). The postoperative suction drainage within 24 h in group A was significantly decreased (243.24 ± 201.52 vs. 504.22 ± 341.08, p = .002). The incidence of postoperative acute kidney injury (AKI) in group A was lower than that in group B (3.8% vs. 14.8%, p = .023). Similarly, the incidence of postoperative hepatic insufficiency in group A was lower than that in group B (1.9% vs. 9.3%, p = .045). In group A, the mechanical ventilation time was shorter (47.68 ± 28.61 vs. 118.21 ± 173.16, p = .004) along with reduced intensive care unit stay time (4.06 ± 1.18 vs. 8.09 ± 9.42, p = .003), and postoperative hospitalization days (19.20 ± 14.60 vs. 23.50 ± 7.56, p = .004). CONCLUSION Preoperative administration of human fibrinogen in patients undergoing ATAAD surgery can effectively reduce the intraoperative blood loss, amount of blood transfused, operation time, and postoperative complications, and improve the early prognosis of patients. In addition, this procedure is highly safe.
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Affiliation(s)
- Jiahui Li
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Qingsong Wu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Mirong Tang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Yue Shen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Zhihuang Qiu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Xiaodong Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Xingfeng Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fuzhou, Fujian, People's Republic of China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, Fujian, People's Republic of China
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11
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Gauger MS, Kaufmann P, Kamber F, Quitt J, Berdajs D, Bolliger D, Mauermann E. Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study. Semin Cardiothorac Vasc Anesth 2022; 26:209-220. [PMID: 35616448 DOI: 10.1177/10892532221088216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. AIMS To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. METHODS We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. RESULTS Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/μL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). CONCLUSIONS "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.
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Affiliation(s)
- Maria S Gauger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Philip Kaufmann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Firmin Kamber
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Jonas Quitt
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Denis Berdajs
- Clinic for Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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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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Right ventricular laceration caused by sternal wire fracture following cardiac surgery: a case report. Indian J Thorac Cardiovasc Surg 2022; 38:418-421. [DOI: 10.1007/s12055-022-01333-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022] Open
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14
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Five-minute Test to Prevent Postcardiotomy Re-exploration. JTCVS Tech 2022; 12:121-129. [PMID: 35403041 PMCID: PMC8987325 DOI: 10.1016/j.xjtc.2021.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/16/2021] [Indexed: 11/22/2022] Open
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15
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Akhrass R, Gillinov M, Bakaeen F, Akras D, Cameron SJ, Bishop J, Kapadia S, Svensson L. Emergency cardiac surgery in patients on oral anticoagulants and antiplatelet medications. J Card Surg 2021; 37:214-222. [PMID: 34779523 DOI: 10.1111/jocs.16027] [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: 05/11/2021] [Revised: 08/06/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency surgery, blood transfusion, and reoperation for bleeding have been associated with increased operative morbidity and mortality. The recent increased use of direct oral anticoagulants and antiplatelet medications has made the above more challenging. In addition, cardiopulmonary bypass (CPB), with its associated hemodilution, fibrinolysis, and platelet consumption, may exacerbate the pre-existing coagulopathy and increase the risk of bleeding. AIM The aim of this study was to examine available literature with regard to treating patients who are on the above medications and require emergency cardiac surgery. RESULTS Management decisions are typically made on a case-by-case basis. Surgery is delayed when possible, and less invasive percutaneous options should be considered if feasible. Attention is paid to exercising meticulous techniques, avoiding excessive hypothermia, and treating coexisting issues such as sepsis. Ensuring a dry operative field upon entry by correcting the coagulopathy with reversal agents is offset by the concern of potentially hindering efforts to anticoagulate the patient (heparin resistance) in preparation for CPB, in addition to possibly increasing the risk of thromboembolism. CONCLUSION Proper knowledge of anticoagulants, their reversal agents, and the usefulness of laboratory testing are all essential. Platelet transfusion remains the mainstay for antiplatelet medications. Four-factor prothrombin complex concentrate is considered in patients on oral anticoagulants if CPB needs to be instituted quickly. Specific reversal agents such as idarucizumab and andexanet alfa can be considered if significant tissue dissection is anticipated, such as redo sternotomy, but are costly and may lead to heparin resistance and anticoagulant rebound.
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Affiliation(s)
- Rami Akhrass
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deena Akras
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott J Cameron
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jay Bishop
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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16
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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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17
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Qazi SM, Kandler K, Olsen PS. Reoperation for bleeding in an elective cardiac surgical population - Does it affect survival? J Cardiovasc Thorac Res 2021; 13:198-202. [PMID: 34630966 PMCID: PMC8493226 DOI: 10.34172/jcvtr.2021.34] [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: 10/20/2020] [Accepted: 05/04/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Earlier studies have shown that re-operation for bleeding after cardiac surgery is associated with increased mortality and morbidity in both acute and elective patients. The aim of the study was to assess the effect of re-operation for bleeding on short- and long-term survival and the causes of re-operation on an exclusively elective population. Methods: This was a single-center, retrospective study conducted at the Department of Cardiothoracic Surgery at Copenhagen University Hospital. Rigshospitalet, Denmark. We included all elective patients undergoing first-time coronary bypass, valve surgery or combinations hereof between January 1998 and February 2014. Data was obtained from the electronic patient records on demographics, cardiological risk profile, blood transfusion and surgical record. Results: A total of 11813 patients were included in the analysis of whom 626 (5.3%) patients underwent re-operation for bleeding. Patients were divided into two groups; non re-operated (NRO) and re-operated(RO). Baseline characteristics were comparable. Median survival was lover in the RO group (142 vs 160months (P = 0.001)). Morbidity and 30 day mortality was significantly higher in the RO group. Cox-regression analysis showed a significantly increased age-adjusted risk of death in the RO group (HR 1.21(1.07-1.37). P = 0.003). In 85% of the patients the site of bleeding was found during the re-operation. Conclusion: We found both short and long-term survival to be lower in the RO group. A surgical cause for re-operation was found in the majority of cases. The study shows the importance of meticulous hemostasis during cardiac surgery.
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Affiliation(s)
| | - Kristian Kandler
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
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18
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Kikura M, Suzuki Y, Sato T, Uraoka M, Kawashima S. Effect of an assessment of fibrin-based rotational thromboelastometry on blood transfusion and clinical outcomes in cardiovascular surgery: A cohort study. Transfus Apher Sci 2021; 60:103202. [PMID: 34238708 DOI: 10.1016/j.transci.2021.103202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/11/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022]
Abstract
The clinical importance of viscoelastic testing in patient blood management when performing cardiovascular surgery is increasing. We aimed to examine the effect of a blood transfusion protocol including an assessment of fibrin-based rotational thromboelastometry on transfusion volume, mortality, and bleeding complications in patients undergoing cardiac or thoracic aortic surgery. We retrospectively studied a cohort of 376 consecutive patients who underwent cardiopulmonary bypass before (control group: 150 cardiac and 35 thoracic aortic surgeries) and after (assessment group: 154 cardiac and 37 thoracic aortic surgeries) introducing the fibrin polymerization assessment with thromboelastometry in the blood transfusion protocol. The transfusion volume and clinical outcomes were compared between the control and assessment groups, and the standardized (mean) difference (S[M]D) was calculated as an indicator of statistical effect size. Compared with the control group, the assessment group had a lower total blood transfusion volume (mL) in cardiac (2720 ± 1282 vs. 2034 ± 1330, p < 0.0001, [SMD] = 0.68) and thoracic aortic surgeries (5236 ± 2732 vs. 3714 ± 1768, p < 0.0001, SMD = 0.67). The 1-year mortality rates were 1.9 % and 2.7 % in cardiac and thoracic aortic surgeries, respectively. Significant differences were not observed in the 1-year mortality (3.2 % vs. 1.0 %, p = 0.16, relative risk [RR] = 0.32 with 95 % confidence intervals [CI] = 0.06-1.57, SD = 0.15), re-exploration for bleeding (4.8 % vs. 2.6 %, p = 0.28, RR = 0.53 with 95 % CI = 0.18-1.57, SD = 0.12), and major bleeding (17.3 % vs. 13.0 %, p = 0.31, RR = 0.75 with 95 % CI = 0.46-1.22, SD = 0.12) rates between the control and assessment groups. The assessment of fibrin polymerization with thromboelastometry using the blood transfusion protocol reduced the blood transfusion volume in cardiovascular surgery.
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Affiliation(s)
- Mutsuhito Kikura
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan.
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tsunehisa Sato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masahiro Uraoka
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan
| | - Shingo Kawashima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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19
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Impact of ABO blood group on bleeding complications after surgery for acute type A aortic dissection. Blood Coagul Fibrinolysis 2021; 32:253-258. [PMID: 33955859 DOI: 10.1097/mbc.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Excessive bleeding is a serious complication associated with impaired survival after surgery for acute type A aortic dissection (ATAAD). Different ABO blood groups are associated with variable levels of circulating von Willebrand factor and therefore potentially altered risks of surgical haemorrhage. The current study aimed to assess the impact of blood group on bleeding complications after ATAAD surgery. This was a retrospective cohort study including 336 patients surgically treated for ATAAD between January 2004 and January 2019. Patients with blood group O were compared with non-O patients. In total, 152 blood group O patients were compared with 184 non-O patients. There were no differences in rates of massive bleeding (27.0 vs. 25.5%, P = 0.767) or re-exploration for bleeding (16.4 vs. 13.0%, P = 0.379) in blood group O and non-O patients, respectively. Median chest tube output 12 h after surgery was 520 ml (350-815 ml) in blood group O and 490 ml (278-703 ml) in non-O patients (P = 0.229). Blood group O patients received more fibrinogen concentrate (6.1 ± 4.0 vs. 4.9 ± 3.3 g, P = 0.023) but administered units of packed red blood cells [5 (2-8) vs. 4 (2-9) U, P = 0.736], platelets [4 (2-4) vs. 3 (2-5) U, P = 0.521] or plasma [4 (1-7) vs. 4 (0-7) U, P = 0.562] were similar. This study could not demonstrate any association between blood group and bleeding after surgery for ATAAD. It cannot be ruled out that potential differences were levelled out by blood group O patients receiving significantly more fibrinogen concentrate.
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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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21
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Luan T, Zhuang Y, Nie W, Yang S, Wu Y, Wang R, Dai Y, Zhang H. The death risk factors of patients undergoing re-exploration for bleeding or tamponade after isolated off-pump coronary artery bypass grafting: a case-control study. BMC Cardiovasc Disord 2021; 21:204. [PMID: 33888070 PMCID: PMC8063367 DOI: 10.1186/s12872-021-02017-2] [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: 01/30/2021] [Accepted: 04/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background The purpose of the study is to identify off-pump patients who are at higher risk of mortality after re-exploration for bleeding or tamponade. Methods We analyzed the data of 3256 consecutive patients undergoing isolated off-pump coronary artery bypass grafting (OPCABG) in our heart center from 2013 through 2020. Fifty-eight patients underwent re-exploration after OPCABG. The 58 patients were divided into death group and survival group according to their discharge status. Propensity score matching (PSM) was performed to analysis the risk factors of death. 15 pairs of cases of two groups were matched well. Results The mortality rate of patients underwent re-exploration after OPCABG for bleeding or tamponade was 27.59% (16/58). In the raw data, we found the patients in death group had higher body mass index (BMI) (P = 0.030), higher cardiac troponin T (cTnT) (P = 0.028) and higher incidence of heart failure before OPCABG (P = 0.003). After PSM, the levels of lactic acid before and after re-exploration (P = 0.028 and P < 0.001) were higher in death group. And the levels of creatinine (P = 0.002) and cTnT (P = 0.017) were higher in the death group after re-exploration. The death group had longer reoperation time (P = 0.010). In addition, the perioperative utilization rate of intra-aortic ballon pump (IABP) (P = 0.027), continuous renal replacement therapy (CRRT) (P < 0.001) and platelet transfusion (P = 0.017) were higher than survival group. Conclusions The mortality rate of patients undergoing re-exploration for bleeding or tamponade after isolated OPCABG is high. More attention should be paid to patients with above risk factors and appropriate measures should be taken in time.
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Affiliation(s)
- Tongxiao Luan
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China.,Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China
| | - Yingzhu Zhuang
- Qingdao Fuwai Cardiovascular Hospital, 201 Nanjing Road, Qingdao, 266034, Shandong Province, China
| | - Weihong Nie
- Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China
| | - Sumin Yang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yuhui Wu
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Rongmei Wang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yunyan Dai
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Hong Zhang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China. .,Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China.
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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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Wang EHZ, Ye J, Turgeon R. Safety and Efficacy of Non-Vitamin K Oral Anticoagulant Use Early After Cardiac Surgery: A Systematic Review. Ann Pharmacother 2021; 55:1525-1535. [PMID: 33813916 DOI: 10.1177/10600280211006830] [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] Open
Abstract
OBJECTIVE To determine the safety and efficacy of non-vitamin K oral anticoagulants (NOACs) initiated early after cardiac surgery. DATA SOURCES: Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE (database inception to January 20, 2021), www.clinicaltrials.gov, www.who.int/ictrp/search/en/, NOAC trial registries, and bibliographies of relevant guidelines and other reviews were used. STUDY SELECTION AND DATA EXTRACTION Observational studies and randomized controlled trials (RCTs) that initiated NOACs within the index hospitalization and that reported bleeding for the primary outcome were included. DATA SYNTHESIS A total of 6 cohort studies, 1 RCT, and 3 ongoing RCTs were included. Most studies were single-centered, limited to postoperative atrial fibrillation after coronary artery bypass grafting, and with 30-day follow-up; few studies included patients with isolated bioprosthetic valve replacement or valve repair. Bleeding risk varied (0%-28.6%), and all but one study showed no significantly higher risk with NOAC compared with warfarin. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Overall, NOACs were used in 26% to 37.5% of patients early after cardiac surgery. Starting a NOAC on postoperative day 4 appeared to have similar bleeding rates compared with warfarin, but clinical application is limited by heterogeneity of outcome definitions, confounding, and bias. Compared with warfarin, NOACs may have similar thromboembolism risk, reduced length of stay, and cost. CONCLUSIONS There is limited evidence to guide NOAC use early after cardiac surgery. Three ongoing randomized trials will add to the literature and provide guidance for clinicians on whether, in whom, when, and how to use NOACs safely early after cardiac surgery.
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Affiliation(s)
| | - Jian Ye
- University of British Columbia, Vancouver, BC, Canada
| | - Ricky Turgeon
- University of British Columbia, Vancouver, BC, Canada
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24
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Wang S, Griffith BP, Wu ZJ. Device-Induced Hemostatic Disorders in Mechanically Assisted Circulation. Clin Appl Thromb Hemost 2021; 27:1076029620982374. [PMID: 33571008 PMCID: PMC7883139 DOI: 10.1177/1076029620982374] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanically assisted circulation (MAC) sustains the blood circulation in the body of a patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) or on ventricular assistance with a ventricular assist device (VAD) or on extracorporeal membrane oxygenation (ECMO) with a pump-oxygenator system. While MAC provides short-term (days to weeks) support and long-term (months to years) for the heart and/or lungs, the blood is inevitably exposed to non-physiological shear stress (NPSS) due to mechanical pumping action and in contact with artificial surfaces. NPSS is well known to cause blood damage and functional alterations of blood cells. In this review, we discussed shear-induced platelet adhesion, platelet aggregation, platelet receptor shedding, and platelet apoptosis, shear-induced acquired von Willebrand syndrome (AVWS), shear-induced hemolysis and microparticle formation during MAC. These alterations are associated with perioperative bleeding and thrombotic events, morbidity and mortality, and quality of life in MCS patients. Understanding the mechanism of shear-induce hemostatic disorders will help us develop low-shear-stress devices and select more effective treatments for better clinical outcomes.
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Affiliation(s)
- Shigang Wang
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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25
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Yanagawa B, Ribeiro R, Lee J, Mazer CD, Cheng D, Martin J, Verma S, Friedrich JO. Platelet Transfusion in Cardiac Surgery: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2021; 111:607-614. [DOI: 10.1016/j.athoracsur.2020.04.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
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26
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Bastopcu M, Özhan A, Erdoğan SB, Kehlibar T. Factors associated with excessive bleeding following elective on-pump coronary artery bypass grafting. J Card Surg 2021; 36:1277-1281. [PMID: 33484200 DOI: 10.1111/jocs.15364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Excessive bleeding following cardiac surgery is associated with worse outcomes. We aimed to analyze preoperative and operative factors associated with excessive bleeding in coronary artery bypass patients to better understand which patients are under increased risk. METHODS The study was conducted as an observational study in a tertiary center for cardiac surgery by retrospective analysis of the hospital database. Patients were grouped according to chest tube output within the postoperative 24 h. Patients in the 4th percentile of chest tube output per kilogram were categorized as having excessive bleeding. Patients with excessive bleeding were compared with the other patients for preoperative and operative factors. Factors significant in univariate analysis were carried onto the multivariate analysis. RESULTS Patients with excessive bleeding were more likely to be males (91.4% vs. 78.7%, p = .002), have lower body mass index (BMI) (27.4 vs. 29.2, p < .001), and low platelets (6.9% vs. 1.5%, p = .006). Cardiopulmonary bypass (101.8 vs. 110.9 min, p = .022) time was longer in the excessive bleeding group. Patients with excessive bleeding were more likely to have more than three vessels revascularized. Male sex, lower BMI, low platelets, and longer cardiopulmonary bypass time were independently associated with increased bleeding. CONCLUSION Male sex, lower BMI, low platelet count, and longer cardiopulmonary bypass time are associated with extensive bleeding after elective coronary artery bypass surgery (CABG). Patients with higher bleeding risk should be identified preoperatively to account for adverse outcomes after CABG.
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Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Abdulkerim Özhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç B Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tamer Kehlibar
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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27
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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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Akhrass R, Bakaeen FG, Akras Z, Houghtaling PL, Soltesz EG, Gillinov AM, Svensson LG. Primary isolated CABG restrictive blood transfusion protocol reduces transfusions and length of stay. J Card Surg 2020; 35:2506-2511. [PMID: 33043652 DOI: 10.1111/jocs.14718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac surgery accounts for 10-15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG). METHODS Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and low-dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared. RESULTS CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P < .0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (P = .02), with no significant differences in mortality or morbidity. CONCLUSIONS A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.
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Affiliation(s)
- Rami Akhrass
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Cardiothoracic Surgery, Lake Health System, Willoughby, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zade Akras
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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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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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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Zatolokin VV, Lomaev MA, Vecherskiĭ II, Abdimitalip UZ, Kozlov BN. [Blood loss control during endoscopic vein harvesting for myocardial revascularization in patients with acute coronary syndrome]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:156-162. [PMID: 32597897 DOI: 10.33529/angio2020224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
From 5 to 10% of patients presenting with acute coronary syndrome and receiving dual antiplatelet therapy require surgical myocardial revascularization. Dual antiplatelet therapy considerably increases the risk of surgical bleeding. Endoscopic harvesting of the great saphenous vein is a technique that can make it possible to decrease the injury and to minimize blood loss. The study included a total of 32 patients presenting with acute coronary syndrome and undergoing coronary artery bypass grafting. They were subdivided into two groups: Group One (study group) was composed of 17 patients subjected to endoscopic harvesting of the great saphenous vein in the flap. Group Two (comparison group) consisted of 15 patients undergoing an open technique of harvesting of the vein in the flap. During the entire perioperative period, the amount of discharge through drainages from the mediastinum did not differ significantly (958±173 ml for Group One patients and 1005±165 ml for Group Two patients, p=0.47). The amount of discharge from the bed of the great saphenous vein on the lower extremities in Group One patients turned out to be less than in Group Two patients (443±37 ml vs. 570±77 ml, p=0.04). A higher haemoglobin content in the total blood count was observed in the postoperative period in the Study Group patients (90±30 g/l vs. 74±21 g/l, respectively, p=0.03). The necessity to use donor blood preparations in Group One patients turned out to be less (transfusion of erythrocytic mass 0 and 2 (0; 2) doses, p=0.001; fresh frozen plasma 2 (0; 3) and 5 (3; 8) doses, respectively, p=0.0001). The duration of hospital stay amounted to 8±1.1 days in the study group and to 15±4.5 days in the comparison group (p<0.0001). Hence, this approach makes it possible to control blood loss in high-risk patients undergoing coronary artery bypass grafting on the background of dual antiplatelet therapy, to decrease the amount of donor blood, and to reduce the length of hospital stay.
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Affiliation(s)
- V V Zatolokin
- Department of Cardiovascular Surgery, Scientific Research Institute of Cardiology, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - M A Lomaev
- Department of Cardiovascular Surgery, Scientific Research Institute of Cardiology, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - Iu Iu Vecherskiĭ
- Department of Cardiovascular Surgery, Scientific Research Institute of Cardiology, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - U Zh Abdimitalip
- Department of Cardiovascular Surgery, Scientific Research Institute of Cardiology, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - B N Kozlov
- Department of Cardiovascular Surgery, Scientific Research Institute of Cardiology, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
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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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Aggarwal NK, Subramanian A. Antifibrinolytics and cardiac surgery: The past, the present, and the future. Ann Card Anaesth 2020; 23:193-199. [PMID: 32275035 PMCID: PMC7336973 DOI: 10.4103/aca.aca_205_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/05/2019] [Accepted: 03/09/2019] [Indexed: 12/02/2022] Open
Abstract
Cardiac surgery is usually associated with significant blood loss, which often necessitates blood transfusion. In order to decrease the risks associated with the latter, pharmacological as well as nonpharmacological strategies have been used to reduce blood loss. Among the pharmacological approaches, antifibrinolytic drugs are the mainstay. Aprotinin, which was the first ubiquitously used drug, fell into disrepute only to re-emerge after much debate. The decline of aprotinin paved the way for the lysine analogs. However, we must be aware with the side effects of these drugs as well as the dose modification required in special situations. Nonsaccharide glycosaminoglycans have been under investigation to overcome the drawbacks of the lysine analogs. It remains to be seen whether these drugs can replace the traditional antifibrinolytics.
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Affiliation(s)
- Naresh K Aggarwal
- Department of Cardiac Anesthesia, Manipal Hospitals, New Delhi, India
| | - Arun Subramanian
- Department of Cardiac Anesthesia, Manipal Hospitals, New Delhi, India
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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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Knapik P, Cieśla D, Saucha W, Knapik M, Zembala MO, Przybyłowski P, Kapelak B, Kuśmierczyk M, Jasiński M, Tobota Z, Maruszewski BJ, Zembala M. Outcome Prediction After Coronary Surgery and Redo Surgery for Bleeding (From the KROK Registry). J Cardiothorac Vasc Anesth 2019; 33:2930-2937. [DOI: 10.1053/j.jvca.2019.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/29/2019] [Accepted: 04/29/2019] [Indexed: 11/11/2022]
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Ertugay S, Kudsioğlu T, Şen T. Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2019; 27:429-450. [PMID: 32082905 PMCID: PMC7018143 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Affiliation(s)
- Serkan Ertugay
- Department of Cardiovascular Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Türkan Kudsioğlu
- Anesthesiology and Reanimation, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Taner Şen
- Department of Cardiology, University of Health Sciences, Kütahya
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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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The design of an adaptive clinical trial to evaluate the efficacy of platelets stored at low temperature in surgical patients. J Trauma Acute Care Surg 2019. [PMID: 29521797 DOI: 10.1097/ta.0000000000001876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Storage of platelets at 4°C compared with 22°C may increase both hemostatic activity and storage duration; however, the maximum duration of cold storage is unknown. We report the design of an innovative, prospective, randomized, Bayesian adaptive, "duration finding" clinical trial to evaluate the efficacy and maximum duration of storage of platelets at 4°C. METHODS Patients undergoing cardiac surgery and requiring platelet transfusions will be enrolled. Patients will be randomized to receive platelets stored at 22°C up to 5 days or platelets stored at 4°C up to 5 days, 10 days, or 15 days. Longer durations of cold storage will only be used if shorter durations at 4°C appear noninferior to standard storage, based on a four-level clinical hemostatic efficacy score with a NIM of a half level. A Bayesian linear model is used to estimate the hemostatic efficacy of platelet transfusions based on the actual duration of storage at 4°C. RESULTS The type I error rate, if platelets stored at 4°C are inferior, is 0.0247 with an 82% probability of early stopping for futility. With a maximum sample size of 1,500, the adaptive trial design has a power of over 90% to detect noninferiority and a high probability of correctly identifying the maximum duration of storage at 4°C that is noninferior to 22°C. CONCLUSION An adaptive, duration-finding trial design will generate Level I evidence and allow the determination of the maximum duration platelet storage at 4°C that is noninferior to standard storage at 22°C, with respect to hemostatic efficacy. The adaptive trial design helps to ensure that longer cold storage durations are only explored once substantial supportive data are available for the shorter duration(s) and that the trial stops early if continuation is likely to be futile.
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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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41
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Panfilov DC, Kozlov BN, Zatolokin VV, Ponomarenko IV, Khodashinsky IA, Shipulin VM. Prevention of hemorrhagic complications during operations on the thoracic aorta. ACTA ACUST UNITED AC 2018. [DOI: 10.15829/1560-4071-2018-11-70-76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Aim. To assess the efficiency of guideline for the prevention of hemorrhagic complications in the early postoperative period.Material and methods. In the period from 2008 to 2017, 166 patients with pathology of the thoracic aorta were operated. The patients were divided into 2 comparable groups: group 1 — patients with reconstructed aortic arch of the type “Hemiarch” (group “hemiarch”, n=90), group 2 — patients with fully reconstructed aortic arch (group “arch”, n=76). All operations were performed with artificial blood circulation, circulatory arrest with moderate hypothermia (2528° C) and unilateral antegrade cerebral perfusion through the brachiocephalic trunk.Results. The reconstructions of the thoracic aorta in patients of the “hemiarch” group were accompanied by significantly less period of artificial blood circulation (p=0,027), cardiac arrest period (p=0,012), duration of circulatory arrest (p=0,019), and duration of antegrade brain perfusion (p=0,021). The volume of discharge through the drainage was 350 [192;506] ml and 400 [250;723] ml in the “hemiarch” and “arch” groups, respectively (p=0,29). Patients of the “arch” group more often required transfusion of packed red cells (p=0,003), fresh frozen plasma (p=0,0006), platelet concentrate (p=0,002) in comparison with patients of the “hemiarch” group. At the same time, the frequency of bleeding requiring reoperation was comparable in both groups (5,6% versus 5,3%, p=0,969). The 30day mortality also had no statistically significant differences in patients of the “hemiarch” and “arch” groups (3,3% versus 9,2%, p=0,119).Conclusion. The frequency of hemorrhagic complications requiring reoperation in patients with a fully or partially reconstructed aortic arch does not have significant differences when using the guideline for preventing of hemorrhagic complications, which makes it possible to provide acceptable frequency of bleeding episodes and reoperations in the early postoperative period.
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Affiliation(s)
| | - B. N. Kozlov
- Tomsk National Research Medical Center of RAS; Siberian State Medical University
| | | | | | - I. A. Khodashinsky
- Tomsk National Research Medical Center of RAS;Tomsk State University of Control Systems and Radioelectronics
| | - V. M. Shipulin
- Tomsk National Research Medical Center of RAS; Siberian State Medical University
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Bolliger D, Tanaka KA. Which Came First, the Chicken or the Egg?—Clinical Dilemmas in Managing Postoperative Bleeding and Decision-making for Re-exploration After Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:1625-1626. [DOI: 10.1053/j.jvca.2018.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Indexed: 11/11/2022]
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Ohmes LB, Di Franco A, Guy TS, Lau C, Munjal M, Debois W, Li Z, Krieger KH, Schwann AN, Leonard JR, Girardi LN, Gaudino M. Incidence, risk factors, and prognostic impact of re-exploration for bleeding after cardiac surgery: A retrospective cohort study. Int J Surg 2018; 48:166-173. [PMID: 29104127 DOI: 10.1016/j.ijsu.2017.10.073] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postoperative re-exploration for bleeding (RB) is a frequent complication following cardiac surgery. We aim to assess incidence, risk factors, and prognostic significance of RB in a large cohort of cardiac patients. MATERIALS AND METHODS We reviewed prospectively collected data for all patients who underwent cardiac surgery at our institution from 2007 to 2015. Logistic regression analysis was used to identify independent predictors of RB and specific outcomes. Propensity matching using a 1:1-ratio compared outcomes of patients who had RB with patients who did not. RESULTS During the study period, 7381 patients underwent cardiac operations. Of them, 189 (2.6%) underwent RB. RB was an independent predictor of in-hospital mortality (Odds Ratio (OR):2.62 Confidence Interval (CI):1.38-4.96; p = 0.003), major adverse events (OR:3.94, CI:2.79-5.62; p < 0.001), gastrointestinal events (OR:3.54 CI:1.73-7.24), renal failure (OR:2.44, CI:1.23-4.82), prolonged ventilation (OR:3.83, CI:2.60-5.62, p < 0.001), and sepsis (OR:2.50, CI:1.03-6.04, p = 0.043). Preoperative shock (OR:3.68, CI:1.66-8.13; p = 0.001), congestive heart failure (OR:1.70 CI:1.24-2.32; p = 0.001), and urgent and emergent status (OR:2.27, CI:1.65-3.12 and OR:3.57, CI:1.89-6.75; p < 0.001 for both) were predictors of RB operative mortality. Operative mortality, incidence of major adverse events, gastrointestinal events, and respiratory failure were all significantly higher in the propensity matched RB group (p = 0.050, p < 0.001, p = 0.046, and p < 0.001 respectively). CONCLUSIONS RB significantly increases in-hospital mortality and morbidity after cardiac surgery.
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Affiliation(s)
- Lucas B Ohmes
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - T Sloane Guy
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Monica Munjal
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - William Debois
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Zhongyi Li
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Karl H Krieger
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Alexandra N Schwann
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Jeremy R Leonard
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States.
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Recombinant factor VIIa use in acute type A aortic dissection repair: A multicenter propensity-score-matched report from the Nordic Consortium for Acute Type A Aortic Dissection. J Thorac Cardiovasc Surg 2017; 154:1852-1859.e2. [DOI: 10.1016/j.jtcvs.2017.08.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/04/2017] [Accepted: 08/05/2017] [Indexed: 11/17/2022]
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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How detrimental is reexploration for bleeding after cardiac surgery? J Thorac Cardiovasc Surg 2017; 154:927-935. [DOI: 10.1016/j.jtcvs.2016.04.097] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 03/28/2016] [Accepted: 04/05/2016] [Indexed: 11/22/2022]
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Ranucci M, Baryshnikova E, Pistuddi V, Menicanti L, Frigiola A. The effectiveness of 10 years of interventions to control postoperative bleeding in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 24:196-202. [PMID: 27756812 DOI: 10.1093/icvts/ivw339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/05/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives Postoperative bleeding in cardiac surgery remains an important complication, leading to increased morbidity and mortality. Different interventions are possible to prevent/treat postoperative bleeding. The present study aims to investigate the effectiveness of these interventions in a real-world scenario. Methods This is a retrospective study based on 19 670 consecutive adult cardiac surgery patients operated from 2000 to 2015. During the study period, the following interventions have been applied and tested for effectiveness with a before versus after analysis: thromboelastography (TEG)-based diagnosis and treatment in actively bleeding patients; platelet function tests (PFTs); timing of surgery based on PFTs; fresh frozen plasma (FFP)-free strategy using prothrombin complex concentrate and fibrinogen concentrate. Results TEG-based diagnostic and therapeutic approach resulted in a significant (P = 0.006) reduction of postoperative bleeding and significant (P = 0.001) increase in platelet concentrate transfusion rate. Timing of surgery based on PFTs resulted in a significant reduction of postoperative bleeding (P = 0.001), surgical re-exploration rate (P = 0.002), FFP (P = 0.001) and platelet concentrate (P = 0.016) transfusion rate. FFP-free strategy was associated with a significant decrease in postoperative bleeding (P = 0.005) and FFP transfusions (P = 0.001). The combination of all the interventions was associated with a significant (P = 0.001) reduction in postoperative bleeding, surgical re-exploration rate and FFP transfusions, whereas platelet concentrate transfusion rate was significantly (P = 0.001) higher. Conclusions Despite a continuous increase in the bleeding risk profile, the application of a bundle of interventions is effective in controlling postoperative bleeding and related complications. Platelet transfusions remain unreplaceable in the present scenario.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Ekaterina Baryshnikova
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Valeria Pistuddi
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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Zindovic I, Sjögren J, Bjursten H, Björklund E, Herou E, Ingemansson R, Nozohoor S. Predictors and impact of massive bleeding in acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2017; 24:498-505. [PMID: 28093462 DOI: 10.1093/icvts/ivw425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/30/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives Bleeding complications associated with acute type A aortic dissection (aTAAD) are a well-known clinical problem. Here, we evaluated predictors of massive bleeding related to aTAAD and associated surgery and assessed the impact of massive bleeding on complications and survival. Methods This retrospective study of 256 patients used Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) criteria to define massive bleeding, which was met by 66 individuals (Group I) who were compared to the remaining patients (Group II). Multivariable logistic regression was used to identify independent predictors of massive bleeding and in-hospital mortality, Kaplan-Meier estimates for analysis of late survival, and Cox regression analysis to evaluate independent predictors of late mortality. Results Independent predictors of massive bleeding included symptom duration (odds ratio [OR], 0.974 per hour increment; 95% confidence interval [CI], 0.950-0.999; P = 0.041) and DeBakey type 1 dissection (OR, 2.652; 95% CI, 1.004-7.008; P = 0.049). In-hospital mortality was higher in Group I (30.3% vs 8.0%, P <0.001). Kaplan-Meier estimates of survival indicated poorer survival for Group I at 1, 3 and 5 years (68.8 ± 5.9% vs 92.8 ± 1.9%; 65.2 ± 6.2% vs 85.3 ± 2.7%; 53.9 ± 6.9% vs 82.1 ± 3.3 %, respectively; log rank P < 0.001). Re-exploration for bleeding was an independent predictor of in-hospital (OR, 3.109; 95% CI, 1.044-9.256; P = 0.042) and late mortalities (hazard ratio, 3.039; 95% CI, 1.605-5.757; P = 0.001). Conclusions Massive bleeding in patients with aTAAD is prompted by shorter symptom duration and longer extent of dissection and has deleterious effects on outcomes of postoperative complications as well as in-hospital and late mortalities.
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Affiliation(s)
- Igor Zindovic
- Department of Cardiothoracic Surgery, and Cardiology, Institute of Clinical Sciences, Lund University, Skane University Hospital, SE, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery, and Cardiology, Institute of Clinical Sciences, Lund University, Skane University Hospital, SE, Lund, Sweden
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery, and Cardiology, Institute of Clinical Sciences, Lund University, Skane University Hospital, SE, Lund, Sweden
| | - Erik Björklund
- Department of Cardiology, University Hospital of Uppsala, Sweden
| | - Erik Herou
- Department of Neurosurgery, Lund University Hospital, Lund, Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, and Cardiology, Institute of Clinical Sciences, Lund University, Skane University Hospital, SE, Lund, Sweden
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