Transfusion Timing and Postoperative Myocardial Infarction and Death in Patients Undergoing Common Vascular Procedures

Transfusion and Anemia in Patients Undergoing Vascular Surgery

This cohort study examines the association between blood transfusion and major adverse cardiovascular events and mortality among people undergoing elective open vascular operations.

Preoperative Assessment of Patients with Vascular Disease

Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.

A novel model for predicting a composite outcome of major complications after valve surgery

Background

On-pump valve surgeries are associated with high morbidity and mortality. The present study aimed to reliably predict a composite outcome of postoperative complications using a minimum of easily accessible clinical parameters.

Methods

A total of 7,441 patients who underwent valve surgery were retrospectively analyzed. Data for 6,220 patients at West China Hospital of Sichuan University were used to develop a predictive model, which was validated using data from 1,221 patients at the Second Affiliated Hospital of Zhejiang University School of Medicine. The primary outcome was a composite of major complications: all-cause death in hospital, stroke, myocardial infarction, and severe acute kidney injury. The predictive model was constructed using the least absolute shrinkage and selection operator as well as multivariable logistic regression. The model was assessed in terms of the areas under receiver operating characteristic curves, calibration, and decision curve analysis.

Results

The primary outcome occurred in 129 patients (2.1%) in the development cohort and 71 (5.8%) in the validation cohort. Six variables were retained in the predictive model: New York Heart Association class, diabetes, glucose, blood urea nitrogen, operation time, and red blood cell transfusion during surgery. The C-statistics were 0.735 (95% CI, 0.686-0.784) in the development cohort and 0.761 (95% CI, 0.694-0.828) in the validation cohort. For both cohorts, calibration plots showed good agreement between predicted and actual observations, and ecision curve analysis showed clinical usefulness. In contrast, the well-established SinoSCORE did not accurately predict the primary outcome in either cohort.

Conclusions

This predictive nomogram based on six easily accessible variables may serve as an "early warning" system to identify patients at high risk of major complications after valve surgery.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT04476134].

Association of Intraoperative and Perioperative Transfusions with Postoperative Cardiovascular Events and Mortality after Infrainguinal Revascularization

BACKGROUND

Patients undergoing open or endovascular infrainguinal revascularization are at elevated risk for postoperative cardiovascular complications due to high rates of comorbidities and the physiologic stress of surgery. Transfusions are known to be associated with adverse events, but knowledge of specific risks associated with transfusion timing, product type, and long-term outcomes while accounting for preoperative cardiovascular risk factors is not well understood in this population.

AIM

This study aimed to characterize the association of intraoperative and perioperative transfusion, anemia, and cardiovascular risk factors with cardiovascular events and mortality in patients undergoing infrainguinal revascularization.

METHODS

A single-center retrospective study was performed on 564 infrainguinal revascularization procedures, including both open (n=250) and endovascular (n=314) approaches (2016-2020). Comprehensive clinical data were collected including patient demographics, cardiovascular risk factors, preoperative hemoglobin, and detailed transfusion data. Multivariable logistic regression tested the association of transfusions with composite 30-day outcomes of cardiac complications (postoperative myocardial infarction [postop-MI], congestive heart failure [CHF], or dysrhythmia) and with major adverse cardiovascular events (MACE- postop-MI or death). Kaplan-Meier analysis and cox-proportional hazard modeling examined the association of transfusions, anemia, and cardiovascular risk factors with mortality up to 1 year.

RESULTS

Intraoperative transfusion was performed in 15% of cases and 13% underwent transfusion in the early postoperative period. Intraoperative transfusion was associated with higher Revised Cardiac Risk Index (RCRI), lower preoperative hemoglobin, increased blood loss and open procedures (all p<0.05). Within each RCRI score, intraoperative transfusion was associated with 2-4 fold increased MACE at 30 days. Intraoperative pRBC transfusion and early postoperative pRBC transfusion was associated with more than 2-fold adjusted odds of any cardiovascular complication and intraoperative transfusion was also associated with MACE (all p<0.05). Intraoperative transfusion was associated with mortality at one year on unadjusted analysis, but after adjustment for RCRI, age, and preoperative hemoglobin, only RCRI scores of 2 and 3+ and preoperatively hemoglobin remained significant risk factors for mortality.

CONCLUSIONS

Intraoperative and early perioperative transfusions are strongly associated with worse cardiovascular outcomes after infrainguinal revascularization. These findings may have prognostic value for further risk stratifying patients perioperatively at high risk for complications. However, prospective studies are needed to elucidate whether optimizing transfusion strategies mitigates these risks.

Thrombocytopenia as an Independent Prognostic Indicator Following Extradural Spinal Tumor Resection

BACKGROUND

Few studies have examined the prognosis for patients with baseline thrombocytopenia undergoing extradural spine tumor resection.

OBJECTIVE

To evaluate mortality, readmission, and other 30-day outcomes in patients with varying degrees of preoperative thrombocytopenia undergoing osseous extradural tumor excision.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2011-2019. Patients were categorized according to baseline preoperative platelet count, in 25,000/μL increments: 125,000-149,000/μL, 100,000-125,000/μL, 75,000-100,000/μL, and < 75,000/μL. These were compared to a control group with platelet count >150,000/μL. Outcomes in each cohort were analyzed using multivariate logistic regression analysis.

RESULTS

The database search revealed 3,574 patients undergoing extradural tumor resection; 2,171 (4.8%) of patients with platelets 125,000-149,000/μL, 114 (3.2%) with 100,000-125,000/μL, 75,000-100,000/μL in 43 (1.2%), and < 75,000/μL in 42 (1.2%). Platelet counts <100,000/μL was associated with perioperative blood transfusion, cardiac complications, and non-home discharge, and 30-day mortality. On subgroup analysis for mortality, an interaction was present between individuals with moderate/severe thrombocytopenia and cervical tumors.

CONCLUSION

In patients undergoing surgery for extradural spine tumor, degree of baseline thrombocytopenia-rather than presence alone-is an independent predictor of several adverse events. Wherever possible, optimization of preoperative platelet count to at least 100,000/μL may improve outcomes.