Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis

Evaluating the Effectiveness of Tranexamic Acid vs. Placebo in Cardiac Surgery: A Systematic Review and Meta-Analysis

Tranexamic acid (TXA), a potent antifibrinolytic agent, is widely used in cardiac surgical procedures worldwide to minimize surgical bleeding and reduce the need for perioperative blood transfusions. However, the use of TXA may increase the risk of coronary artery graft thrombosis, potentially leading to a higher occurrence of late thrombotic events. Some studies have suggested that drugs like TXA, aimed at decreasing bleeding during cardiac surgeries, may be associated with elevated risks of thrombotic complications or mortality. Conversely, the reduced need for blood transfusions could contribute to improved long-term outcomes. Thus, a systematic review and meta-analysis were undertaken to assess the efficacy of TXA in cardiac surgery patients. Searches were conducted in databases including PubMed and PubMed Central. Data were extracted, and their quality was assessed using the Cochrane risk of bias tool for randomized clinical trials (RCTs). A random effects model was used to compute the pooled prevalence and investigate heterogeneity using the I2 statistic. Subgroup analyses differentiated between experimental and placebo groups. Additionally, sensitivity analyses were performed to assess the robustness of the findings, and publication bias was examined. An overall sample size of 12,869 patients was included in the meta-analysis, derived from seven of the 10 selected articles. This pooled sample was used to conduct an analysis of TXA's efficacy in cardiac surgery patients. Subgroup analysis revealed a 95% heterogeneity and indicated a p-value of less than 0.05, favoring TXA over placebo in terms of better outcomes. Our research indicates a statistically significant relationship between the efficacy of TXA and the number of patients undergoing heart surgery. According to our findings, there is a pressing need to enhance this evidence base and conduct larger RCTs to better understand the benefits of using TXA, aiming to maintain a low risk of bleeding after both major and minor heart surgeries.

Clinical Predictors and Outcomes After Left Ventricular Assist Device Implantation and Tracheostomy

BACKGROUND

Postoperative respiratory failure is a major complication that affects up to 10% of patients who undergo cardiac surgery and has a high in-hospital mortality rate. Few studies have investigated whether patients who require tracheostomy for postoperative respiratory failure after continuous-flow left ventricular assist device (CF-LVAD) implantation have worse survival outcomes than patients who do not.

OBJECTIVE

To identify risk factors for respiratory failure necessitating tracheostomy in CF-LVAD recipients and to compare survival outcomes between those who did and did not require tracheostomy.

METHODS

Consecutive patients who underwent primary CF-LVAD placement at a single institution between August 1, 2002, and December 31, 2019, were retrospectively reviewed. Propensity score matching accounted for baseline differences between the tracheostomy and nontracheostomy groups. Multivariate logistic regression was used to identify tracheostomy risk factors and 90-day survival; Kaplan-Meier analysis was used to assess midterm survival.

RESULTS

During the study period, 664 patients received a CF-LVAD; 106 (16.0%) underwent tracheostomy for respiratory failure. Propensity score matching produced 103 matched tracheostomy-nontracheostomy pairs. Patients who underwent tracheostomy were older (mean [SD] age, 57.9 [12.3] vs 54.6 [13.9] years; P = .02) and more likely to need preoperative mechanical circulatory support (61.3% vs 47.8%; P = .01) and preoperative intubation (27.4% vs 8.8%; P < .001); serum creatinine was higher in the tracheostomy group (mean [SD], 1.7 [1.0] vs 1.4 [0.6] mg/dL; P < .001), correlating with tracheostomy need (odds ratio, 1.76; 95% CI, 1.21-2.56; P = .003). Both before and after propensity matching, 30-day, 60-day, 90-day, and 1-year survival were worse in patients who underwent tracheostomy. Median follow-up was 0.8 years (range, 0.0-11.2 years). Three-year Kaplan-Meier survival was significantly worse for the tracheostomy group before (22.0% vs 61.0%; P < .001) and after (22.4% vs 48.3%; P < .001) matching.

CONCLUSION

Given the substantially increased probability of death in patients who develop respiratory failure and need tracheostomy, those at high risk for respiratory failure should be carefully considered for CF-LVAD implantation. Comprehensive management to decrease respiratory failure before and after surgery is critical.

Planned Reoperation after Cardiac Surgery in the Cardiac Intensive Care Unit

Background

Cardiac surgical re-exploration for bleeding is associated with increased morbidity and mortality. Whether to perform these procedures in the operating room (OR) or the Cardiac Intensive Care Unit (CICU) in uncertain. We sought to determine if the location of the reoperation would affect postoperative outcomes when a reoperation for bleeding is required following cardiac surgery.

Methods

Patients who underwent planned cardiac re-explorations for bleeding at our center from January 2019 to December 2021 were retrospectively enrolled in this study. Patient outcomes were compared and analyzed.

Results

Due to hemorrhagic shock, 72 patients underwent planned cardiac re-explorations, including 21 operated in the CICU and 51 in the OR. Within 12 h of the primary operation, 65 re-explorations (90.3%) were performed. The peak Vasoactive-Inotropic Score was 47.0 ± 27.4, systolic blood pressure was 89.4 ± 9.6 mmHg, central venous pressure was 12.1 ± 4.4 cmH 2 O, and the serum lactate was 5.5 ± 4.1 mmol/L prior to the reoperation. Multivariate logistic analysis showed that a reoperation performed in the CICU was not an independent risk factor for the occurrence of major complications. There was no significant difference in mortality between the two groups.

Conclusions

Planned re-exploration for bleeding following open cardiac surgery in the CICU is feasible and safe.

Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study

Background

More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear.

Methods

In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death.

Results

The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026).

Conclusion

We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.

Cardiac surgery receipt and outcomes for people using secondary mental healthcare services: Retrospective cohort study using a large mental healthcare database in South London

BACKGROUND

Patients diagnosed with mental health problems are more predisposed to cardiovascular disease, including cardiac surgery. Nevertheless, health outcomes after cardiac surgery for patients with mental health problems as a discrete group are unknown. This study examined the association between secondary care mental health service use and postoperative health outcomes following cardiac surgery.

METHODS

We conducted a retrospective observational research, utilizing data from a large South London mental healthcare supplier linked to national hospitalization data. OPCS-4 codes were applied to classify cardiac surgery. Health results were compared between those individuals with a mental health disorder diagnosis from secondary care and other local residents, including the length of hospital stay (LOS), inpatient mortality, and 30-day emergency hospital readmission.

RESULTS

Twelve thousand three hundred and eighty-four patients received cardiac surgery, including 1,481 with a mental disorder diagnosis. Patients with mental health diagnosis were at greater risk of emergency admissions for cardiac surgery (odds ratio [OR] 1.60; 1.43, 1.79), longer index LOS (incidence rate ratio 1.28; 1.26, 1.30), and at higher risk of 30-day emergency readmission (OR 1.53; 1.31, 1.78). Those who underwent pacemaker insertion and major open surgery had worse postoperative outcomes during index surgery hospital admission while those who had major endovascular surgery had worse health outcomes subsequent 30-day emergency hospital readmission.

CONCLUSION

People with a mental health disorder diagnosis undertaking cardiac surgery have significantly worse health outcomes. Personalized guidelines and policies to manage preoperative risk factors require consideration and evaluation.

Use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery: a scoping review protocol

INTRODUCTION

A major complication of cardiac surgery is bleeding which can require surgical re-exploration and the transfusion of allogeneic blood products. Re-operative procedures for bleeding have been associated with higher rates of mortality and morbidity, therefore an intervention to reduce this complication would be important. Previous investigation has demonstrated that low-cost solutions, such as the use of an intraoperative haemostatic checklist may result in the reduction of bleeding and subsequent transfusion. The goals of this scoping review aim to assess the efficacy of the use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery. Specifically, the objective is to understand if the use of intraoperative haemostatic checklists has been associated with a reduction in bleeding and blood product utilisation in patients undergoing non-emergent cardiac surgery.

METHODS AND ANALYSIS

A scoping review of literature identifying randomised control and observational trials, reporting on haemostatic checklists in cardiac surgery, will be undertaken. The proposed review will be guided by the methodological framework proposed by Arksey and O'Malley. A search will be conducted for published and unpublished (grey) literature. Published literature will be searched in the following electronic databases: Scopus, MEDLINE, EMBASE and the Cochrane Library. Relevant grey literature will be identified through conference abstracts. Outcomes chosen are patient centred to ensure reduced bleeding and overall positive experience that reduces complications intraoperatively.

ETHICS AND DISSEMINATION

This study does not require ethical approval as the data used are from available publications. Our dissemination strategy includes peer-review publication, presentation at conferences and relevant stakeholders.

Analysis of prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery

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.

Video-Assisted Thoracoscopic Surgery Management of Subacute Retained Blood Syndrome after Cardiac Surgery

PURPOSE

Blood loss along with inadequate evacuation after cardiac surgery leads to retained blood syndrome (RBS) in the pleural and/or pericardial cavity. Re-sternotomy is often needed for clot evacuation. Video-assisted thoracoscopic surgery (VATS) evacuation is a less-invasive procedure. However, sufficient evidence on safety and outcomes is lacking.

METHODS

Thirty patients who developed hemothorax and/or hemopericardium after cardiac surgery and underwent VATS evacuation between April 2015 and September 2020 were included in this retrospective single-center analysis.

RESULTS

The median patient age was 70 (interquartile range: IQR 62-75) years, body mass index (BMI) was 24.7 (IQR 22.8-29) kg/m2, time between initial cardiac surgery and VATS was 17 (IQR 11-21) days, 30% of the patients were female, 60% resided in the ICU, and 17% were nicotine users. Coronary artery bypass graft was the most frequent initial cardiac procedure. Median operation time was 120 (IQR 90-143) min, 23% of the patients needed an additional VATS, and the median length of hospital stay after VATS was 8 (IQR 5-14) days. All patients survived VATS, and we experienced no mortality related to the VATS procedure.

CONCLUSION

In our study, VATS for evacuation of RBS after cardiac surgery was a feasible, safe, and efficient alternative approach to re-sternotomy in selected patients.

Fibrinogen and Bleeding in Adult Cardiac Surgery: A Review of the Literature

Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.

Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting

Background

Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG).

Methods

A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival.

Results

Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500–1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival.

Conclusions

Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.

Bleeding Complications in Patients With Perioperative COVID-19 Infection Undergoing Cardiac Surgery: A Single-Center Matched Case-Control Study

Objective

Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients.

Design

Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection.

Setting

Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area.

Participants

In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score.

Interventions

Open-heart cardiac surgery on CPB.

Measurements and Main Results

In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively).

Conclusions

A worrisome increased risk of early and late bleeding complications in COVID-19 patients was observed, and it should be considered when assessing the operative risk. CPB-related inflammatory reaction could exacerbate the deleterious effect of COVID-19 on the coagulation system and likely deviate it toward a hemorrhagic pattern.

Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons

Surgical re-explorations represent 3-5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: "planned" and "unplanned". Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs. 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs. 7%, p = 0.004), prolonged intubation (46.8% vs. 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs. 7%, p = 0.91) and DSWI rates (1.8% vs. 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Device-Induced Hemostatic Disorders in Mechanically Assisted Circulation

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.

The synergistic effect of tranexamic acid and ethamsylate combination on blood loss in pediatric cardiac surgery

Background:

Pediatric patients are at risk for bleeding after cardiac surgery. Administration of antifibrinolytic agents reduces postoperative blood loss.

Objective:

Evaluation of the efficacy of combined administration of tranexamic acid (TXA) and ethamsylate in the reduction of postoperative blood loss in pediatric cardiac surgery.

Methods:

This prospective randomized study included 126 children submitted for cardiac surgery, and they were allocated into three groups: control group (n = 42); TXA group (n = 42):- received only TXA; and combined ethamsylate TXA group (n = 42):- received a combination of TXA and ethamsylate. The main collected data included sternal closure time, the needs for intraoperative transfusion of blood and its products, the total amount of blood loss, and the amount of the whole blood and its products transfused to the patients in the first 24 postoperative hours.

Results:

Blood loss volume in the first 24 postoperative hours was significantly smaller in combined group than the TXA and control groups and was significantly smaller in the TXA group than the control group. The sternal closure time was significantly shorter in the combined group than the other 2 groups and significantly shorter in TXA than the control group. The amount of whole blood transfused to patients in the combined group during surgery and in the first postoperative 24 h was significantly smaller than the other 2 groups and smaller in TXA group than the control group during surgery.

Conclusion:

Combined administration of ethamsylate and TXA in pediatric cardiac surgery was more effective in reducing postoperative blood loss and whole blood transfusion requirements than the administration of TXA alone.

Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk.

PURPOSE

Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design.

METHODS

The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products.

RESULTS

A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time.

CONCLUSION

The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.

Comparison Effect of Tranexamic Acid (TA) and Tranexamic Acid Combined with Vitamin C (TXC) on Drainage Volume and Atrial Fibrillation Arrhythmia in Patients Undergoing Cardiac Bypass Surgery: Randomized Clinical Trial

BACKGROUND

Tranexamic acid and vitamin C are potent antifibrinolytic and oxidative stress agents that reduce blood loss and transfusion blood in cardiopulmonary bypass (CPB).

OBJECTIVES

The aim of this study was to evaluate the efficacy of tranexamic acid (TA) and tranexamic acid combined with vitamin C (TXC) on drainage volume (blood loss) and atrial fibrillation (AF) in patients undergoing cardiac bypass surgery in Gorgan, Shafa hospital, Iran.

METHODS

This study is a double-blind randomized clinical trial. A sample size of 120 candidates of cardiac bypass surgery were included in this prospective study. Patients were randomly assigned to treatments in two groups. In both groups, 50 mg/kg tranexamic acid was administered intravenously directly before sternotomy: group A (N = 58) patients received tranexamic acid (TA) only and group B (N = 62) tranexamic acid with vitamin C (TXC) half an hour before surgery and 2 g vitamin C with 100 mL 0.9% saline were injected. Subsequently, during 4 days after surgery, 1000 mg of vitamin C and 100 cc 0.9% saline was infused every day. Intraoperative and postoperative blood loss (volume of blood in the drain) and atrial fibrillation complications were recorded for 24 hours after the operation.

RESULTS

The patients who received vitamin C had less bleeding during operation and in the early hours post-operation. Patients in (TA) group had mean drainage of 34.41 milliliter more than patients in (TXC) group (P < 0.001). Chi-square test showed that arrhythmia (AF) condition was the same in the two groups during 14 times of study (four times during operation and ten times up to 24 hours after the operation), and AF arrhythmia in the two groups was less than 5%.

CONCLUSIONS

In this study tranexamic acid with vitamin C have a positive effect on the amount of drainage (blood loss) and there was no significant difference in the incidence of AF between two groups.

Feasibility and acceptability of continuous postoperative pericardial flushing for blood loss reduction in patients undergoing coronary artery bypass grafting

INTRODUCTION

Postoperative bleeding requires blood transfusion and surgical re-exploration that can affect the short- and long-term postoperative outcomes. Interventions that can be used in the postoperative period to reduce blood loss should be developed. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. This study examined the feasibility and acceptability of CPPF for reducing bleeding after coronary artery bypass surgery.

METHODS

This pilot study adopted a prospective and group comparison design. Between January and April 2018, 42 patients who underwent isolated coronary artery bypass surgery received CPPF from sternal closure up to 8 h postoperative. The mean actual blood loss in the CPPF group was compared to the mean of retrospectively group (n = 58). In the CPPF group, an extra infusion catheter was inserted through one of the tube incision holes and an irrigation solution (0.9% NaCl at 38 °C) was delivered to the pericardial cavity by using a volumetric pump. Safety aspects, feasibility issues, and complications were documented. The primary outcome was blood loss, and it was assessed 18 h after the surgery.

RESULTS

CPPF was successfully completed in 40 patients (95.24%). Method-related complications were not observed. Feasibility was good in this experimental setting. Blood loss was lower in the CPPF group (257.24 mL) than non-CPPF group (p < 0.001).

CONCLUSIONS

CPPF after coronary artery bypass grafting surgery is safe, effective, feasible, and acceptable. However, standardized randomized clinical trials are necessary to draw definitive conclusions.

Development and validation of a measurement system for continuously monitoring postoperative reservoir levels

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.

Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety

OBJECTIVE

To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y₁₂ inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications.

DATA SOURCES

A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations.

STUDY SELECTION AND DATA EXTRACTION

In all, 18 original research reports and case reports/series were included in the review.

DATA SYNTHESIS

Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y₁₂ inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding.

CONCLUSIONS

Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.

Predictive value of ScvO2 monitoring for pericardial tamponade after cardiac surgery

BACKGROUND

We examined the predictive value of central venous oxygen saturation (ScvO2) changes regarding the occurrence of pericardial tamponade following cardiac surgery.

METHODS

We retrospectively identified 66 consecutive patients in whom ScvO2 and arterial lactate levels were analyzed during an 8‑h time interval preceding pericardiotomy due to pericardial tamponade (PT), and at equivalent time points in 30 control patients (C) who had an uncomplicated course.

RESULTS

The median age of the patients was 74 years (interquartile range, 63-78). Three percent of procedures were re-operations. There were no differences between the baseline values of PT and C patients. Pericardiotomy was performed on average 1 day (0-3.5) after cardiac surgery. PT patients displayed a significant decline (p < 0.001) to lower ScvO2 levels (p < 0.001) and a significant increase (p = 0.005) to higher arterial lactate levels (p = 0.019) during the 8 h preceding pericardiotomy, whereas C patients did not (p = 0.440 and p = 0.279, respectively). PT was associated with a longer hospital stay (p = 0.04) and a higher in-hospital mortality (p = 0.008). An ScvO2 decline below 60% (p = 0.018), a delta ScvO2 decline greater than 5% (p = 0.001), and a delta lactate increase greater than 0.18 mmol/l (p = 0.002) during the 8 h preceding pericardiotomy were independently associated with PT. None of these parameters predicted in-hospital mortality.

CONCLUSION

Deteriorations in ScvO2 might serve as an early marker of PT following cardiac surgery.

The effectiveness of 10 years of interventions to control postoperative bleeding in adult cardiac surgery

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.

Massive bleeding in cardiac surgery. Definitions, predictors and challenges

BACKGROUND

Severe or massive bleeding in cardiac surgery is an uncommon but important clinical scenario. Its existing definitions are diverse. Its characteristics constantly change during an active hemorrhage and, thus is difficult to define appropriately.

METHODS

In this narrative, non-systematic review, we performed a literature search to retrieve data that could contribute to answering clinical questions on the definition and grading of severe hemorrhage and massive transfusion, identifying factors that predict and affect bleeding and transfusion-related mortality and describing the risks of re-exploration and the economic impact of severe bleeding in cardiac surgery.   Results: Massive perioperative bleeding is currently described by indices of its rate and extent and the magnitude of the consequent blood products transfusion. It has a significant impact on mortality, service logistics, and hospital financing. Proper and early identification of a massive bleeding is possible. Among other factors, patient's co-morbidities, bleeding severity and transfusion volume seem to predict the associated mortality. Consequent to severe bleeding, re-exploration, is also a potentially hazardous adverse event that also affects morbidity and mortality.

CONCLUSIONS

Severe perioperative hemorrhage in cardiac surgery carries significant morbidity and mortality. Currently, prediction and identification of massive bleeding is a feasible but incomplete clinical task despite the availability of effective treatment regimens. A still missing, compact definition of massive perioperative bleeding in cardiac surgery that incorporates all phases of treatment could augment clinical preparedness, allow for the development of accurate prediction tools and permit the application of well-validated protocols of management. Hippokratia 2016, 20(3): 179-186.

Continuous Postoperative Pericardial Flushing: A Pilot Study on Safety, Feasibility, and Effect on Blood Loss

BACKGROUND

Prolonged or excessive blood loss is a common complication after cardiac surgery. Blood remnants and clots, remaining in the pericardial space in spite of chest tube drainage, induce high fibrinolytic activity that may contribute to bleeding complications. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. In this pilot study, the safety and feasibility of CPPF were evaluated and the effect on blood loss and other related complications was investigated.

METHODS

Between November 2011 and April 2012 twenty-one adult patients undergoing surgery for congenital heart disease (CHD) received CPPF from sternal closure up to 12 h postoperative. With an inflow Redivac drain that was inserted through one of the chest tube incision holes, an irrigation solution (NaCl 0.9% at 38 °C) was delivered to the pericardial cavity using a volume controlled flushing system. Safety aspects, feasibility issues and complications were registered. The mean actual blood loss in the CPPF group was compared to the mean of a retrospective group (n = 126).

RESULTS

CPPF was successfully completed in 20 (95.2%) patients, and no method related complications were observed. Feasibility was good in this experimental setting. Patients receiving CPPF showed a 30% (P = 0.038) decrease in mean actual blood loss 12 h postoperatively.

CONCLUSIONS

CPPF after cardiac surgery was found to be safe and feasible in this experimental setting. The clinically relevant effect on blood loss needs to be confirmed in a randomized clinical trial.

The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery

OBJECTIVE

Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin's anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery.

METHODS

This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets.

RESULTS

No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets.

CONCLUSIONS

In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets.

The Effect of Intravenous Administration of Active Recombinant Factor VII on Postoperative Bleeding in Cardiac Valve Reoperations; A Randomized Clinical Trial

BACKGROUND

Postoperative bleeding after cardiac reoperations is among the most complicating problems, both for the physicians and for the patients. Many modalities have been used to decrease its adverse effects and the need for blood products administration.

OBJECTIVES

In a randomized double-blinded clinical trial of redo cardiac valve surgery in adult, the effect of active recombinant factor VII (rFVIIa) on postoperative bleeding was compared with placebo. Chest tube drainage was used for comparison of bleeding between the two groups.

PATIENTS AND METHODS

Two groups of 18 patients undergoing redo valve surgeries were treated and compared regarding chest tube drainage, need for blood products, prothrombin time (PT), partial thromboplastin time (PTT), hemoglobin and hematocrit, platelet count, and international normalized ratio (INR) in first 24 hours after surgery. Bleeding was assessed at 3rd, 12th, and 24th hour after operation. In rFVIIa group, 40 µg/kg of AryoSeven was administered before end of surgery and same volume of normal saline was administered as placebo in the control group.

RESULTS

Study groups showed no difference regarding baseline variables. Three patients in rFVIIa group (16.67%) and 13 in placebo group (72.23%) received blood products (P < 0.01). Chest tube blood drainage at 24th hour after operation was 315 ± 177 mL in rFVIIa group and 557 ± 168 mL in control group (P = 0.03). At third and 12th hour after operation, the difference was not statistically significant (P = 0.71 and P = 0.22, respectively). Postoperative ICU stay was not different; while extubation was longer in the placebo group (352 ± 57 vs. 287 ± 46 minutes; P = 0.003).

CONCLUSIONS

Our study demonstrated the efficacy of rFVIIa in controlling postoperative bleeding in redo cardiac valve surgeries regarding subsequent blood loss and transfusion requirement; however, outcome results remains to be defined.

Planned cardiac reexploration in the intensive care unit is a safe procedure

BACKGROUND

Cardiac surgical reexploration is necessary in approximately 5% of all patients. However, the impact of routine, planned reexploration performed in the intensive care unit (ICU) remains poorly defined. This study evaluated postoperative outcomes after cardiac reexplorations to determine the safety and efficacy of a planned approach in the ICU.

METHODS

All patients undergoing ICU cardiac reexplorations (2000 to2011) at a single institution were stratified according to a routine, planned ICU approach to reexploration (planned) versus unplanned ICU or operating room reexploration. Patient risk and outcomes were compared by univariate and multivariate analyses.

RESULTS

8,151 total patients underwent cardiac operations, including 267 (3.2%) reexplorations (planned ICU=75% and unplanned ICU=18%). Among planned ICU reexplorations, 38% of patients had an identifiable surgical bleeding source, and 60% underwent reexploration less than 12 hours after the index procedure. Unplanned ICU reexplorations had a higher Society of Thoracic Surgeons (STS) predicted mortality (5% vs 3%, p<0.001) and incurred higher observed mortality (37% vs 6%, p<0.001) and morbidity. Sternal wound infections were rare and were similar between groups (p=0.81). Furthermore, upon STS mortality risk adjustment, unplanned ICU reexplorations were associated with significantly increased odds of mortality (OR=26.6 [7.1, 99.7], p<0.001) compared with planned ICU reexplorations.

CONCLUSIONS

Planned reexploration in the ICU is a safe procedure with acceptable mortality and morbidity and low infection rates. Unplanned reexplorations, however, increase postoperative risk and are associated with high mortality and morbidity. These data argue for coordinated, routine approaches to planned ICU reexploration to avoid delay in treatment for postoperative hemorrhage.

The effect of prior percutaneous coronary intervention on the immediate and late outcome after coronary artery bypass grafting: systematic review and meta-analysis

INTRODUCTION

A number of studies reported on a possible increased risk of morbidity and mortality after coronary artery bypass grafting in patients with prior percutaneous coronary intervention.

METHODS

A systematic review and meta-analysis of studies comparing the outcome of patients undergoing coronary surgery with or without prior percutaneous coronary intervention was performed. Only studies reporting results of adjusted analysis and excluding acute percutaneous coronary intervention failures were included in this meta-analysis.

RESULTS

Literature search yielded nine studies reporting on 68,645 patients who underwent coronary surgery. Of them, 8,358 (12.2%) had a prior percutaneous coronary intervention. Patients without prior percutaneous coronary intervention were significantly older (p=0.002), had significantly higher prevalence of left main stenosis (p=0.005) and three-vessel disease (p<0.0001). Prior percutaneous coronary intervention was associated with higher risk of resternotomy for bleeding (p=0.04) and dialysis (p=0.003). Thirty-day/in-hospital mortality was significantly higher in patients with prior percutaneous coronary intervention (pooled rate: 2.7% vs 2.0%, risk ratio 1.39, 95% confidence interval 1.06-1.84, p=0.02) as confirmed also by generic inverse variance analysis (risk ratio 1.47, 95% confidence interval 1.12-1.93, p=0.005). Prior percutaneous coronary intervention did not affect late outcome (five studies included, risk ratio 1.07, 95% confidence interval 0.90-1.28, p=0.43).

CONCLUSIONS

Prior percutaneous coronary intervention seems to be associated with an increased risk of immediate postoperative morbidity and mortality after coronary surgery, but does not affect late mortality. These results are not conclusive and need to be confirmed by studies of better quality evaluating the impact of indication, timing, type of stents, amount of treated vessels and number of previous percutaneous coronary interventions.

Early and mid-term outcomes of combined aortic valve replacement and coronary artery bypass grafting in elderly patients

OBJECTIVES

Although the number of elderly patients undergoing combined aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) is increasing, the early and mid-term outcomes of this combined procedure remain to be determined. We sought to elucidate the early and mid-term outcomes of elderly (≥75 years) vs non-elderly (<75 years) patients who underwent combined AVR and CABG.

METHODS

Between September 2004 and September 2011, 259 patients underwent combined AVR and CABG at our institute, including 155 elderly patients (59.8%; Elderly group) with a mean age of 79.8 ± 3.6 years and 104 non-elderly patients (40.2%; Non-elderly group) with a mean age of 67.3±5.8 years. Early and mid-term outcomes were compared, and multivariate analyses were performed to determine the risk factors for morbidity and mortality. The mean follow-up times were 33.1±21.7 and 37.4±22.2 months in the Elderly and Non-elderly groups, respectively.

RESULTS

The mean number of anastomoses and the frequency of use of the internal thoracic artery were similar between the two groups. The use of a mechanical valve was less frequent in the Elderly group than in the Non-elderly group (11.6 vs 60.6%, P<0.001). The Elderly and Non-elderly groups had similar rates of operative death (1.9 vs 1.0%, P=0.651), early stroke (2.6 vs 1.0%, P=0.651), 5-year overall survival (83.1±4.8 vs 87.2±5.2%, P=0.358), 5-year freedom from cardiac death (92.3±2.7 vs 94.8±3.4%, P=0.570) and 5-year freedom from stroke (94.0±2.6 vs 99.0±1.0%, P=0.097). Cox proportional hazards analyses identified diabetes, creatinine level and EuroSCORE II, but not age, as independent predictors of overall mortality rate.

CONCLUSIONS

Early and mid-term outcomes of combined AVR and CABG were similar between elderly and non-elderly patients. Older age was not a risk factor for mortality in patients undergoing combined AVR plus CABG, and this procedure should be recommended in properly selected elderly patients.

Use of blood products and risk of stroke after coronary artery bypass surgery

BACKGROUND

The impact of blood transfusion on the development of post-operative stroke after coronary artery bypass grafting (CABG) is not well established. We, therefore, investigated this issue.

MATERIALS AND METHODS

Complete data on peri-operative blood transfusion were available for 2,226 patients who underwent CABG in three Finnish hospitals.

RESULTS

Stroke occurred post-operatively in 53 patients (2.4%). Logistic regression showed that pre-operative creatinine (OR 1.003, 95% CI 1.000-1.006), extracardiac arteriopathy (OR 2.344, 95% CI 1.133-4.847), pre-operative atrial fibrillation (OR 2.409, 95% CI 1.149-5.052), and the number of packed red blood cell units transfused (OR 1.121, 95% CI 1.065-1.180) were significantly associated with post-operative stroke. When the various blood product transfusions instead of transfused units were included in the multivariable analysis, solvent/detergent treated plasma (Octaplas) transfusion (OR 2.149, 95% CI 1.141-4.047), but not red blood cell transfusion, was significantly associated with postoperative stroke. Use of blood products ranging from no transfusion (stroke rate 1.6%) to combined transfusion of red blood cells, platelets and Octaplas was associated with a significant increase in post-operative stroke incidence (6.6%, adjusted analysis: OR 1.727, 95% 1.350-2.209). Patients who received >2 units of red blood cells, >4 units of Octaplas units and >8 units of platelets had the highest stroke rate of 21%. CART analysis showed that increasing amount of transfused Octaplas, platelets and history of extracardiac arteriopathy were significantly associated with post-operative stroke.

CONCLUSIONS

Transfusion of blood products after CABG has a strong, dose-dependent association with the risk of stroke. The use of Octaplas and platelet transfusions seem to have an even larger impact on the development of stroke than red blood cell transfusions.