Risk Factors for Red Blood Cell Transfusion After Coronary Artery Bypass Graft Surgery

The treatment of chronic anemia in heart failure: a global approach

Chronic anemia is an independent risk factor for mortality in patients with heart failure (HF). Restoring physiological hemoglobin (Hb) levels is essential to increase oxygen transport capacity to tissues and improve cell metabolism as well as physical and cardiac performance. Nutritional deficits and iron deficiency are the major causes of chronic anemia, but other etiologies include chronic kidney disease, inflammatory processes, and unexplained anemia. Hormonal therapy, including erythropoietin (EPO) and anabolic treatment in chronic anemia HF patients, may contribute to improving Hb levels and clinical outcomes. Although preliminary studies showed a beneficial effect of EPO therapy on cardiac efficiency and in HF, more recent studies have not confirmed this positive impact of EPO, alluding to its side effect profile. Physical exercise significantly increases Hb levels and the response of anemia to treatment. In malnourished patients and chronic inflammatory processes, low levels of anabolic hormones, such as testosterone and insulin-like growth factor-1, contribute to the development of chronic anemia. This paper aims to review the effect of nutrition, EPO, anabolic hormones, standard HF treatments, and exercise as regulatory mechanisms of chronic anemia and their cardiovascular consequences in patients with HF.

Comparison of minimal invasive extracorporeal circulation versus standard cardiopulmonary bypass systems on coronary artery bypass surgery

Background

In this study, we shared our experience with the minimal invasive extracorporeal circulation system for coronary artery bypass grafting patients.

Methods

A total of 163 patients were included in the retrospective study, with 83 patients (63 males, 20 females; mean age: 61.9±8.9 years; range, 35 to 81 years) undergoing coronary artery bypass grafting with minimal invasive extracorporeal circulation and 80 patients (65 males, 15 females; mean age: 60.5±8.8 years; range, 43 to 82 years) undergoing coronary artery bypass grafting with conventional cardiopulmonary bypass between July 2021 and April 2023. Elective coronary bypass performed by same surgical team were included in the study. Mortality, major adverse cardiac and cerebrovascular event, hospital stays and transfusion requirements were evaluated.

Results

There were no significant differences in sex distribution, age, comorbidities, and blood values between the two groups. Intraoperatively, the minimal invasive extracorporeal circulation group had a slightly higher number of distal anastomoses and comparable times for aortic cross-clamp and cardiopulmonary bypass. Postoperative outcomes such as tamponade, bleeding, atrial fibrillation, left ventricular ejection fraction improvement or reduction, and postoperative drainage were similar between the two groups. However, the minimal invasive extracorporeal circulation group had fewer transfusions of packed red blood cells and fresh frozen plasma and a shorter length of stay in the intensive care unit.

Conclusion

The minimal invasive extracorporeal circulation system effectively preserves blood, works with lower activated clotting time values without additional complications in coronary artery bypass grafting, and could present a better option for patients with anemia or patients with a relatively high risk for high-dose heparinization.

Presurgical circulating platelet-derived microparticles level as a risk factor of blood transfusion in patients with valve heart disease undergoing cardiac surgery

BACKGROUND

Cell-derived microparticles (MPs) are membrane vesicles that have emerged as a potential biomarker for various diseases and their clinical complications. This study investigates the role of MPs as a risk factor for blood transfusion in patients with valve heart disease undergoing cardiac surgery.

METHODS

Forty adult patients undergoing heart valve surgery with cardiopulmonary bypass (CPB) were enrolled, and venous blood samples were collected prior to surgical incision. Plasma rich in MPs was prepared by double centrifugation, and the concentration of MPs was determined using the Bradford method. Flow cytometry analysis was performed to determine MPs count and phenotype. Patients were divided into "with transfusion" (n = 18) and "without transfusion" (n = 22) groups based on red blood cell (RBC) transfusion.

RESULTS

There was no significant difference in MPs concentration between the "with transfusion" and "without transfusion" groups. Although the count of preoperative platelet-derived MPs (PMPs), monocyte-derived MPs (MMPs), and red cell-derived MPs (RMPs) was higher in "without transfusion" group, these differences were not statistically significant. The preoperative PMPs count was negatively correlated with RBC transfusion (P = 0.005, r = -0.65). Multivariate logistic regression analysis revealed that the count of CD41+ PMPs, Hemoglobin (Hb), and RBC count were risk factors for RBC transfusion.

CONCLUSION

This study suggests that the presurgical levels of PMPs, Hb, and RBC count can serve as risk factors of RBC transfusion in patients with valve heart disease undergoing cardiac surgery. The findings provide insights into the potential use of MPs as biomarkers for blood transfusion prediction in cardiac surgery.

Sex-differences in outcome after off-pump coronary artery bypass grafting is age-dependent; data from the Netherlands Heart Registration

Background

Women are known to have worse outcome after coronary artery bypass grafting (CABG) than men. Studies have shown that off-pump coronary artery bypass grafting (OPCAB) might benefit higher-risk patients, and therefore might also benefit women. We aimed to determine differences in early and late outcomes between sexes after OPCAB.

Methods

Data from all patients undergoing OPCAB, between 2013 through 2021 was retrieved from the Netherlands Heart Registration (NHR) database. Primary outcomes were early mortality, morbidity and late survival. We divided the population into subgroups based on age (aged ≥70 years or < 70 years) and sex.

Results

This study included 8,487 men and 2,170 women (total = 10,657). Female patients received fewer anastomoses (mean (SD)) women 2.38 (1.17) vs men 2.68 (1.23), p < 0.001) and total arterial revascularization was performed less frequently in women than in men (21.3 % versus 29.5 % respectively, p < 0.001).In the subgroup of patients <70 years, early mortality was 1.7 % in women and 0.6 % in men (p < 0.001). Survival rate at 5 years was 88.4 % in women and 91.1 % in men (p < 0.001). Female sex was associated with worse late survival in the subgroup <70 years (HR (95 % CI) 1.42 (1.10-1.83) p = 0.008).

Conclusions

Sex-differences in outcome after CABG persists in OPCAB surgery. However, these differences are solely present in the younger subgroup. In our data, women undergoing OPCAB surgery seem to be treated differently during surgery as compared to their male counter parts, further research is needed to analyze this finding.

A transfusion risk stratification score to facilitate quality management in cardiopulmonary bypass

BACKGROUND

Our previous showed that a blood management program in the cardiopulmonary bypass (CPB) department, reduced red blood cell (RBC) transfusion and complications, but assessing transfusion practice solely based on transfusion rates was insufficient. This study aimed to design a risk stratification score to predict perioperative RBC transfusion to guide targeted measures for on-pump cardiac surgery patients.

STUDY DESIGN AND METHODS

We analyzed data from 42,435 adult cardiac patients. Eight predictors were entered into the final model including age, sex, anemia, New York Heart Association classification, body surface area, cardiac surgery history, emergency surgery, and surgery type. We then simplified the score to an integer-based system. The area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow goodness-of-fit test, and a calibration curve were used for its performance test. The score was compared to existing scores.

RESULTS

The final score included eight predictors. The AUC for the model was 0.77 (95% CI, 0.76-0.77) and 0.77 (95% CI, 0.76-0.78) in the training and test set, respectively. The calibration curves showed a good fit. The risk score was finally grouped into low-risk (score of 0-13 points), medium-risk (14-19 points), and high-risk (more than 19 points). The score had better predictive power compared to the other two existing risk scores.

DISCUSSION

We developed an effective risk stratification score with eight variables to predict perioperative RBC transfusion for on-pump cardiac surgery. It assists perfusionists in proactively preparing blood conservation measures for high-risk patients before surgery.

Timing of Blood Transfusions and 30-Day Patient Outcomes After Coronary Artery Bypass Graft Surgery

OBJECTIVE

Packed red blood cell transfusion during coronary artery bypass graft surgery is known to be associated with adverse outcomes. However, the association of the timing between transfusions in relation to discharge and 30-day postoperative outcomes has not been studied. The study authors investigated the impact of transfusion timing on 30-day surgical outcomes.

DESIGN

A retrospective review.

SETTING

At a single tertiary-care academic hospital.

PARTICIPANTS

A total of 2,481 adult patients underwent primary coronary artery bypass graft surgery between January 2014 and December 2020.

MEASUREMENTS AND MAIN RESULTS

The relationship between the timing of packed red blood cell transfusion (intraoperative, postoperative, or both) and 30-day postoperative outcome variables was calculated as an odds ratio. The influence of timing of transfusion on adjusted probability of postoperative complications was plotted against the lowest intraoperative hematocrit. The median age of the population was 67 years (60.0-74.0), body mass index was 28.5 (25.6-32.3) kg/m², and 497 (20.0%) were female. A total of 1,588 (36%) patients received packed red blood cell transfusions; 182 (7.3%) received intraoperative transfusions, 489 (19.7%) received postoperative transfusions, and 222 (9.0%) received both (intraoperative and postoperative transfusions). Postoperative transfusion was associated with significantly higher odds of readmission (1.83 [1.32-2.54], p = 0.002) and heart failure (1.64 [1.2-2.23], p = 0.008) compared to patients with no transfusions; whereas intraoperative transfusions were not.

CONCLUSION

The authors' data suggested that the postoperative timing of transfusion in patients undergoing coronary artery bypass graft surgery may be associated with an increased incidence of 30-day heart failure and readmission. Prospective research is needed to conclusively confirm these findings.

Robotic-assisted versus conventional off-pump coronary surgery in women: A propensity-matched study

BACKGROUND

Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied.

OBJECTIVES

To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes.

METHODS

Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics.

RESULTS

In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization.

CONCLUSIONS

Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.

Robotic hybrid coronary revascularization versus conventional off-pump coronary bypass surgery in women with two-vessel disease

BACKGROUND

Hybrid coronary revascularization (HCR) treats coronary artery disease (CAD) by combining a minimally invasive surgical approach with the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and percutaneous coronary intervention (PCI) for non-LAD vessels. This study aimed to compare immediate and long-term outcomes between robotic HCR and off-pump coronary artery bypass (OPCAB) via sternotomy in women with two-vessel CAD.

METHODS AND RESULTS

We compared all robotic HCR (LIMA-to-LAD plus stent; n = 55) and OPCAB (LIMA-to-LAD plus saphenous vein graft; n = 54) performed at a single institution between May 2005 and January 2021. To adjust for the selection bias of receiving either HCR or OPCAB, we performed a propensity score analysis of 31 matched pairs. In the immediate postoperative period, no statistically significant difference was observed for operative mortality and HCR was associated with lower rates of blood transfusion (25.8% vs. 54.8%; p = .038), and shorter hospital length of stay (4.0 vs. 6.0 days; p = .009). After a mean follow-up of 7.0 ± 4.9 years, we observed no statistically significant differences between the groups for overall survival (hazard ratio [HR]: 0.48, 95% confidence interval [CI]: 0.09-2.64, p = .401), myocardial infarction (HR: 1.60, 95% CI: 0.14-17.64, p = .703), stroke (HR not assessable; almost zero events), target vessel revascularization (HR: 0.45, 95% CI: 0.08-2.47, p = .359), angina (HR: 0.64, 95% CI: 0.20-2.01, p = .444) and major adverse cardiac and cerebrovascular events (HR: 0.46, 95% CI: 0.14-1.52, p = .202).

CONCLUSIONS

Robotic HCR provides for women with two-vessel CAD a shorter postoperative recovery with fewer blood transfusions, with similar long-term outcomes when compared with conventional OPCAB via sternotomy.

Risk-Prediction Model for Transfusion of Erythrocyte Concentrate During Extracorporeal Circulation in Coronary Surgery

INTRODUCTION

Our objective was to identify preoperative risk factors and to develop and validate a risk-prediction model for the need for blood (erythrocyte concentrate [EC]) transfusion during extracorporeal circulation (ECC) in patients undergoing coronary artery bypass grafting (CABG).

METHODS

This is a retrospective observational study including 530 consecutive patients who underwent isolated on-pump CABG at our Centre over a full two-year period. The risk model was developed and validated by logistic regression and bootstrap analysis. Discrimination and calibration were assessed using the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (H-L) test, respectively.

RESULTS

EC transfusion during ECC was required in 91 patients (17.2%). Of these, the majority were transfused with one (54.9%) or two (41.8%) EC units. The final model covariates (reported as odds ratios; 95% confidence interval) were age (1.07; 1.02-1.13), glomerular filtration rate (0.98; 0.96-1.00), body surface area (0.95; 0.92-0.98), peripheral vascular disease (3.03; 1.01-9.05), cerebrovascular disease (4.58; 1.29-16.18), and hematocrit (0.55; 0.48-0.63). The risk model developed has an excellent discriminatory power (AUC: 0,963). The results of the H-L test showed that the model predicts accurately both on average and across the ranges of deciles of risk.

CONCLUSIONS

A risk-prediction model for EC transfusion during ECC was developed, which performed adequately in terms of discrimination, calibration, and stability over a wide spectrum of risk. It can be used as an instrument to provide accurate information about the need for EC transfusion during ECC, and as a valuable adjunct for local improvement of clinical practice. Key Findings: Risk factors with the greatest prediction for EC transfusion. Take-Home Message: The implementation of this model would be an important step in optimizing and improving the quality of surgery.

Did blood transfusion increase mortality in patients with diabetes undergoing isolated coronary artery bypass graft surgery? A propensity score-matched analysis of 816 patients

Background

The aim of this study was to compare clinical outcomes of blood transfusion in patients with diabetes mellitus undergoing isolated on-pump coronary artery bypass grafting.

Methods

The medical records of a total of 1,912 patients (1,300 males, 612 females; mean age 60.7±10.0) with diabetes who underwent isolated on-pump coronary artery bypass grafting between January 1999 and June 2019 were retrospectively analyzed. The patients were divided into two groups as patients with and without blood transfusions. The mortality rates were compared between the two groups.

Results

The mortality rate was 14 times higher in the patients receiving blood transfusion (odds ratio: 14.80; 95% confidence interval 5.05 to 43.34; p<0.001). However, in the multivariate logistic regression analysis, there were no statistically significant difference in mortality between the patient groups, when diabetes mellitus was a covariate factor (Odds ratio: 8.34; 95% confidence interval 3.94 to 17.66 vs. odds ratio 8.36; 95% confidence interval 3.95 to 17.70).

Conclusion

The propensity score-matched analysis of patients with diabetes showed that clinical outcomes were more severely affected by blood transfusion.

Evolution of perioperative blood transfusion practice after coronary artery bypass grafting in the past two decades

BACKGROUND AND AIM OF THE STUDY

Transfusion of blood products after coronary artery bypass grafting (CABG) is associated with increased morbidity and mortality. We evaluated the perioperative use of blood products in patients undergoing CABG in our institution over the past two decades.

METHODS

The study included 18 992 patients who underwent isolated CABG at our hospital between 1998 and 2017. Baseline characteristics of patients and the number of perioperative transfusions during their hospital stay (including red blood cells [RBCs], platelets, and fresh frozen plasma [FFP]) were assessed. Logistic regression models were used to identify risk factors for perioperative transfusion.

RESULTS

The rates of perioperative RBC transfusion decreased for all patients undergoing isolated CABG (52.1% in 1998 vs 18.6% in 2017) in our institution. The mean number of transfused RBC units was significantly higher in women than in men (1.57 ± 2.2 vs 0.68 ± 1.84; P < .005); this difference remained significant over the years. After adjusting the results for other risk factors, female sex was a significant independent risk factor for perioperative RBC transfusion. The platelet transfusion rate increased over the past two decades (1.4% in 1998 vs 9.7% in 2017). The number of FFP transfusions remained unchanged.

CONCLUSIONS

Over the past two decades, we observed a decrease in the incidence of perioperative RBC transfusions in patients undergoing isolated CABG, whereas platelet transfusions increased. Female sex was an independent predictor of perioperative RBC transfusion.

Do women benefit more than men from off-pump coronary artery bypass grafting?

Objectives

Outcomes after coronary artery bypass grafting (CABG) are worse in women than in men. This study aims to investigate whether off-pump coronary artery bypass (OPCAB) surgery improves the outcomes in women by comparing different outcome measures in both genders.

Methods

Patients who underwent isolated CABG, either on-pump (ONCAB) or OPCAB, between January 1998 and June 2017 were included. Primary endpoints were 30-day and 120-day mortality. Logistic regression models were constructed to evaluate the effect of the CABG technique on important outcomes such as mortality and the need for blood transfusion.

Results

The data of 17,052 patients were analysed, 3,684 of whom were women (414 OPCAB) and 13,368 men (1,483 OPCAB). The mean number of grafts was lower in the OPCAB group of both genders (p < 0.001). Postoperatively, both men and women undergoing OPCAB surgery received fewer red blood cell transfusions (p < 0.001) and had higher postoperative haemoglobin levels (p < 0.001) than those undergoing ONCAB. Early mortality occurred less frequently after OPCAB surgery in both genders, although the difference was not significant. However, 120-day mortality was significantly lower after OPCAB surgery in women, even after correction for preoperative risk factors [odds ratio (OR) = 0.356, 95% confidence interval (CI) 0.144–0.882, p = 0.026]. The difference in 120-day mortality was not significant in men (OR = 0.787, 95% CI 0.498–1.246, p = 0.307).

Conclusions

Women undergoing CABG benefit more from OPCAB surgery than from ONCAB surgery in terms of 120-day mortality. This difference was not found in men in our patient population.

Intra-operative red blood cell transfusion and mortality after cardiac surgery

Background

Anemia in cardiac surgery patients has been associated with poor outcomes. Transfusion of red blood cells during surgery is common practice for perioperative anemia, but may come with risks. Little is known about the association between intra-operative transfusion and mortality in patients undergoing cardiac surgery.

Methods

Single centre historical cohort study in 2933 adult patients undergoing coronary surgery with or without aortic valve replacement from June 2011 until September 2014. To estimate the odds ratio for mortality in patients receiving intra-operative transfusion, a propensity score based logistic regression analysis was performed.

Results

Intra-operative transfusion was associated with a more than three-fold increased risk of 30-day mortality. Patients in the highest quartile of probability of transfusion were older (age 75 vs 66; P <  0.001), had a higher EuroSCORE (6 vs 3; P <  0.001), had lower preoperative hemoglobin levels (7.6 vs 8.9 mmol/l; P < 0.001), had combined surgery more often (CABG + AVR in 33.4% of cases vs 6.6% (P < 0.001) and a longer duration of surgery (224 vs 188 min; P < 0.001). The association between intra-operative transfusion and mortality persisted after adjustment for these risk factors (adjusted OR 2.6; P = 0.007).

Conclusions

Intra-operative transfusion of red blood cells was found to be associated with increased mortality in adults undergoing coronary surgery. Preoperative patient optimization may improve perioperative outcomes by reducing the likelihood of requiring transfusion and thus its associated risk.

Gender and intraoperative blood transfusion: analysis of 54,122 non-reoperative coronary revascularization procedures

Background:

Previous studies have shown that women undergoing isolated coronary artery bypass graft (CABG) surgery have an increased risk for postoperative morbidity and mortality when compared to men. Additionally, recent evidence suggests that blood transfusions are independently associated with an increased risk of adverse outcome.

Methods:

We evaluated gender differences in the risk of intraoperative red blood cell (RBC) transfusion during CABG surgery. Consecutive, non-reoperative CABG procedures performed across 196 institutions between April 2012 and May 2015 were retrospectively reviewed. Gender differences for intraoperative transfusion were evaluated with a multi-variable binary logistic regression model, adjusting for age, blood volume (Nadler formula to normalize for height and weight), body mass index, procedure acuity, net extracorporeal circuit prime volume, use of autologous priming, first hematocrit (Hct) in the operating room (OR), nadir Hct on cardiopulmonary bypass (CPB), volume added on CPB, ultrafiltration volume, urine output on CPB and procedure duration.

Results:

Among 54,122 patients (25.3% female), 21.6% (n = 11,701) received a RBC transfusion. Compared to men, female patients were older (66 years vs. 64 years, p<0.001), had lower blood volumes (4.3L vs. 5.6L, p<0.001) and a lower preoperative Hct (32.9% vs. 37.2%, p<0.001). Transfusion rates were three-fold higher in women versus men (45.1% vs. 13.7%, p<0.001). After adjustment for independent predictors of intraoperative transfusion, women remained at increased risk versus men (OR = 1.30, 95%CI = 1.19−1.43).

Conclusions:

Women have an increased risk of intraoperative RBC transfusion versus men. After adjusting for height and weight, much of this risk is due to gender differences in preoperative Hct and blood volume; however, a residual significant risk remained after adjustment. Perfusion strategies aimed at gender differences may minimize unnecessary transfusions. Future study on the impact of gender on transfusion practice in cardiac surgery is warranted.

Utilisation of blood and blood products during open heart surgery in a low-income country: our local experience in 3 years

BACKGROUND

In Nigeria, access to open heart surgery (OHS) is adversely affected by insufficient blood and blood products, including the challenges because of the lack of patient-focused blood management strategies owing to the absent requisite point-of-care tests in the operating theatre (OR)/ICU. In addition, the limited availability of altruistic blood donors including the detection of transfusion transmitted infections more commonly among non-altruistic blood donors is another burden affecting the management of excessive bleeding during and after open heart surgery in our country.

OBJECTIVE

The objective of this study was to review our local experience in the use of blood and blood products during open heart surgery and compare the same with the literature.Materials and methodsIn a period of 3 years (March, 2013-February, 2016), we performed a retrospective review of those who had open heart surgery in our institution. The data were obtained from our hospital health information technology department. The data comprised demography, types of operative procedures and units of blood and blood products transfused per procedure, including the details regarding the usage of the cell saver, as well as those who had severe bleeding requiring excessive blood transfusion.

RESULTS

During the study period, 102 patients had open heart surgery, an average of 34 cases in a year. Among them, there were 75 (73.53%) males and 37 (36.27%) females, giving a ratio of 2:1. The ages of the patients were from 0.6 (7/12) to 74 years. Mitral valve procedure was the most common (n=22, 21.6%) surgery type. Transfusion requirements averaged 1.9 units of fresh frozen plasma, 0.36 units of platelet concentrate, and 1.68 units of packed cells per procedure. The least common surgical procedure was common atrium repair (n=1, 0.01%).

CONCLUSION

Open heart procedure is a very complex procedure requiring cardiopulmonary bypass with associated severe perioperative bleeding. The attendant blood loss and haemostatic challenges are combated by intricate and selective transfusions of allogeneic blood and or blood products.

Bioelectrical Impedance Phase Angle-Predictor of Blood Transfusion in Cardiac Surgery

OBJECTIVE

To determine whether bioelectrical impedance-derived phase angle (PA) can be a predictor of red blood cell (RBC) transfusion in patients undergoing cardiac surgery.

DESIGN

An observational retrospective study of prospectively collected data.

SETTING

Single center, tertiary referral university hospital.

PARTICIPANTS

The study sample comprised 642 adult patients undergoing elective cardiac surgery.

INTERVENTIONS

Patient demographic and clinical variables were collected. The body composition of the patients was evaluated by bioelectrical impedance analysis (BIA) the day prior to surgery. The rates of postoperative RBC transfusion were recorded.

MEASUREMENTS AND MAIN RESULTS

Among the 642 patients (67.8% men, median age of 66 [range 59-73]) included in the present study, 210 (32.7%) received at least 1 RBC unit postoperatively. Hypertension, preoperative stroke, renal failure, preoperative hemoglobin and hematocrit values, BIA-derived PA, aortic crossclamp time, and cardiopulmonary bypass (CPB) time were associated with the risk of RBC transfusion in the univariate analysis, and were included in the final multivariate regression model. Preoperative stroke (odds ratio [OR] 0.394; 95% confidence interval [CI]: 0.183-0.848; p = 0.017), preoperative hemoglobin values (OR 0.943; 95% CI: 0.928-0.960; p < 0.001), PA <15th percentile (OR 2.326; 95% CI: 1.351-4.000; p = 0.002), and CPB time (OR 1.013; 95% CI: 1.008-1.018; p < 0.001) were identified as independent predictors of RBC transfusion.

CONCLUSION

Several factors were identified to be associated significantly with postoperative RBC transfusion in patients undergoing cardiac surgery. Among the conventional predictors, the value of the BIA-derived PA was indicated as a potent prognostic tool.

Early Postoperative Complications for Elderly Patients Undergoing Single-Level Decompression for Lumbar Disc Herniation, Ligamentous Hypertrophy, or Neuroforaminal Stenosis

BACKGROUND

Lumbar decompression for disc herniation is frequently performed on elderly patients, and this trend will continue as the population ages. Clinical reports on the complications of lumbar discectomy show good results and cost effectiveness in young or middle-aged patients.

OBJECTIVE

To assess and compare the morbidity of single-level lumbar disc surgery for radicular pain in a cohort of patients greater than 80 yr of age to that of a middle-aged cohort.

METHODS

A total of 9451 patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy were retrospectively selected from a multicenter validated surgical database from the American College of Surgeons National Surgical Quality Improvement Program. A cohort with 485 patients greater than 80 yr of age (80+) was compared with a middle-aged cohort with 8966 patients between 45 and 65 yr. Preoperative comorbidity and postoperative outcome variables observed included mortality, myocardial infarction, return to the operating room, sepsis, deep vein thrombosis, transfusions, cardiac arrest necessitating cardiopulmonary resuscitation, coma greater than 24 h, urinary tract infection, acute renal failure, use of ventilator greater than 24 h, pulmonary embolism, pneumonia, wound dehiscence, and postoperative infection.

RESULTS

The preoperative comorbidities and characteristics were significantly different between the middle-aged and the 80+ cohorts, with the older cohort having many more preoperative comorbidities. There was statistically significantly greater postoperative morbidity among the 80+ cohort regarding pulmonary embolism (0.8% vs 0.2%, P = .037), intra/postoperative transfusion requirement (1.9% vs 0.7%, P = .01), urinary tract infection (1.2% vs 0.3%, P = .011), and 30-d mortality (0.4% vs 0.1%, P = .046).

CONCLUSION

In this large sample of patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy, elderly patients, particularly with American Society of Anesthesiologists class 3 and 4, had a statistically significant increase in morbidity and mortality, but the overall risk of complications remains low.

Factors influencing transfusion requirement in patients undergoing first-time, elective coronary artery bypass graft surgery

CONTEXT

Coronary artery bypass graft (CABG) operation is associated with high frequency of allogeneic blood transfusion due to the acquired hemostatic challenges in patients undergoing CABG. However, allogeneic blood transfusion carries risks of infection, adverse reaction, and mortality as well as prolonged hospital stay and increased hospital cost. It is important to identify patients who require blood transfusion to mitigate their risk factors and reduce the chance of exposure to allogeneic blood.

AIMS

This study was conducted to evaluate factors that influence the decision to transfuse red cell in first-time elective CABG patients.

SETTINGS AND DESIGN

This was a cross-sectional study based on a retrospective record review. The study was done in the National Heart Institute.

MATERIALS AND METHODS

All patients who underwent first-time elective CABG were included in this study. Variables analyzed include age, gender, body weight, preoperative hemoglobin (Hb) level, patients' comorbidities, and other clinical parameters.

STATISTICAL ANALYSIS USED

Data were analyzed using SPSS software version 20.

RESULTS

A total of 463 patients underwent first-time elective CABG during the period of the study. Three hundred and eighty-six (83.4%) patients received red cell transfusion. From multiple logistic regression analysis, only age (odds ratio [OR] = 1.040, 95% confidence interval [CI]: 1.003, 1.077, P = 0.032), body weight (OR = 0.951, 95% CI: 0.928, 0.974, P < 0.001), Hb level (OR = 0.500, 95% CI: 0.387, 0.644, P < 0.001), and cardiopulmonary bypass time (OR = 1.013, 95% CI: 1.004, 1.023, P < 0.001) were the significant independent predictors of red cell transfusion.

CONCLUSIONS

By stratifying patients according to their risk factor for red cell transfusion, the high-risk patients could be recognized and should be enrolled into effective patient blood management program to minimize their risk of exposure to allogeneic blood transfusion.

Predictors of red blood cell transfusion after cardiac surgery: a prospective cohort study

OBJECTIVE

To identify predictors of red blood cell transfusion (RBCT) after cardiac surgery.

METHOD

A prospective cohort study performed with 323 adults after cardiac surgery, from April to December of 2013. A data collection instrument was constructed by the researchers containing factors associated with excessive bleeding after cardiac surgery, as found in the literature, for investigation in the immediate postoperative period. The relationship between risk factors and the outcome was assessed by univariate analysis and logistic regression.

RESULTS

The factors associated with RBCT in the immediate postoperative period included lower height and weight, decreased platelet count, lower hemoglobin level, higher prevalence of platelet count <150x10(3)/mm (3), lower volume of protamine, longer duration of anesthesia, higher prevalence of intraoperative RBCT, lower body temperature, higher heart rate and higher positive end-expiratory pressure. The independent predictor was weight <66.5Kg.

CONCLUSION

Factors associated with RBCT in the immediate postoperative period of cardiac surgery were found. The independent predictor was weight.

Assessing Intraoperative Bleeding Risk in Patients Undergoing Coronary Artery Bypass Grafting with Prior Exposure to Clopidogrel: Single Center Retrospective Analysis

In patients undergoing coronary artery bypass grafting (CABG), intraoperative and postoperative major bleeding requiring blood transfusions and surgical reexploration is associated with increased mortality and morbidity. Our study hypothesized that exposure to clopidogrel is not significantly associated with increased risk for intraoperative bleeding, even when administered less than 5 days before CABG. We also aimed to determine variables associated with intraoperative packed red blood cell (iPRBC) transfusion. Patients of both sexes aged 18 years or older who underwent CABG from July 1, 2011 to December 31, 2012 were included in the analysis. Study population consisted of 2 groups-clopidogrel arm and nonclopidogrel arm. Patients were included in clopidogrel arm if they were exposed to clopidogrel in the past (as one of their home medications or received the medication for first time during the index hospitalization), whereas patients who never received clopidogrel were included in nonclopidogrel arm. We identified a total of 303 adult patients who underwent CABG with a mean age was 64.5 years. Mortality rate in our study was 0.99% (n = 3) with increased mortality in women as compared with men (3.27% vs. 0.41%, P = 04). The mean iPRBC transfused were 1.68 units, with higher units being transfused in women as compared with men (2.23 vs. 1.49 units, respectively, P = 0.03) and no significant difference between clopidogrel and nonclopidogrel arms (1.92 vs. 1.50, respectively, P = 0.18). After multivariate analysis, age [odds ratio (OR) = 1.03, P = 0.01], female sex (OR = 2.61, P = 0.006) and hypertension (OR = 7.10, P = 0.02) predicted increased iPRBC transfusion. Clopidogrel or nonclopidogrel status was not associated with increased iPRBC transfusion (OR = 1.06, P = 0.81). iPRBC transfusion rates were similar in both arms with age, female sex, and hypertension being an independent predictor of iPRBC transfusion.

Reducing the immediate availability of red blood cells in cardiac surgery, a single-centre experience

Background

In our institution, we have redefined our criteria for direct availability of red blood cell (RBC) units in the operation room. In this study, we sought to evaluate the safety of applying this new logistical policy of blood transfusion in the first preliminary group of patients.

Methods

In March 2010, we started a new policy concerning the elective availability of RBC units in the operation room. This policy was called: No Elective Red Cells (NERC) program. The program was applied for patients undergoing primary isolated coronary artery bypass grafting (CABG) or single valve surgery. No elective RBC units were preoperatively ordered for these patients. In case of urgent need, blood was delivered to the operating room within 20 min. The present study includes the first 500 patients who were managed according to this policy. Logistic regression analyses were performed to investigate the impact of biomedical variables on fulfilling this NERC program.

Results

The majority of patients (n = 409, 81 %) did not receive any RBCs during the hospital stay. In patients who did receive RBCs (n = 91, 19 %), 11 patients (2.2 %) received RBCs after 24 h postoperatively. Female gender, left ventricular ejection fraction (LVEF) and EuroSCORE were significant predictors for the need of blood transfusion (OR = 3.12; 2.79; 1.17 respectively).

Conclusion

In a selected group of patients, it is safe to perform cardiac surgery without the immediate availability of RBCs in the operating room. Transfusion was avoided in 81 % of these patients. Female gender, LVEF and EuroSCORE were associated with blood transfusion.

Risk factors related to transfusion requirements in patients undergoing implantation of ventricular assist devices

OBJECTIVE

The identification of transfusion risk factors in patients receiving left ventricular assist devices to allow for targeted use of blood conservation strategies and improved blood utilization.

DESIGN

This is a retrospective analysis of prospectively collected data between April 2009 and June 2012. Linear regression was used to determine factors associated with increased transfusion. Logistic regression was used to determine factors that were associated with more than the median number of units transfused.

SETTING

Single center, university hospital.

PARTICIPANTS

Patients (n=144) who underwent left ventricular assist device implantation.

INTERVENTION

Transfused blood product data for the day of surgery and for 3 days after were obtained from the blood bank.

MEASUREMENTS AND MAIN RESULTS

Beta-blockers were associated with 1.7±0.65 fewer red blood cell (RBC) units and 2.2±0.7 fewer fresh frozen plasma units transfused. Each year of older age was associated with 0.113±0.023 units of RBC, 0.543±0.101 platelet, and 0.098±0.017 plasma units transfused. International normalized ratio was associated with more platelet transfusion (20.813±5.757 units per 1.0 increase), but not with plasma or RBC transfusion. Lower platelet counts were associated with both platelet (-0.045±0.019 units per 10,000 μL(-1)) and plasma transfusions (-0.011±0.004). Myocardial infarction was associated with increased RBC and plasma transfusion, and cardiogenic shock was associated with increased platelet transfusions, but nitrate use was associated with reduced platelet transfusion.

CONCLUSION

Beta-blockers may be a modifiable factor to decrease transfusions. The association between international normalized ratio and platelet transfusions suggests that better determination of the type of coagulopathy may promote more appropriate transfusions.

Propensity-matched analysis of the effect of preoperative intraaortic balloon pump in coronary artery bypass grafting after recent acute myocardial infarction on postoperative outcomes

Introduction

There is substantial variability in the preoperative use of intraaortic balloon pumps (IABPs) in patients undergoing coronary artery bypass grafting post myocardial infarction. The objective of this study is to determine the effect of preoperative IABPs on postsurgical outcomes in this subset of patients.

Methods

From 2007 to 2012, 877 patients underwent isolated coronary artery bypass post myocardial infarction. Four hundred and six patients were propensity-score matched based on the likelihood of receiving a preoperative balloon pump. Total blood transfusion requirements, composite in-hospital morbidity and/or mortality end point, total hours in the intensive care unit, and length of hospital stay were compared between the two groups.

Results

No significant differences in demographics, preoperative risk factors, intraoperative variables or length of hospital stay were found between patients with and without balloon pumps after propensity score matching. Compared to patients without balloon pumps, a higher percentage of patients with preoperative IABPs required transfusions. Patients with preoperative balloon pumps were more likely to have the composite end point of in-hospital morbidity (24.1% versus 12.8%, P <0.004), and increased hours in the intensive care unit (median hours: 69.0 versus 46.0, P <0.013) as compared to patients without balloon pumps.

Conclusions

The use of preoperative IABPs in patients undergoing isolated coronary artery bypass grafting after myocardial infarction is associated with increased transfusion requirements, increased in-hospital morbidity and longer postoperative intensive care unit stay as compared to patients without IABPs.

Relationship Between Hematocrit Level and Cardiovascular Risk Factors in a Community-Based Population

BACKGROUND

This study aimed to determine the relationship between hematocrit (HCT) levels and cardiovascular risk factors in a community-based population of middle-aged adults.

METHODS

From April 2011 to February 2012, a total of 1,884 middle-aged adults were selected from a community-based population in China. Blood and urine samples were collected for routine blood and urine tests, and measurement of plasma glucose and lipid levels. Baseline information including traditional cardiovascular risk factors was obtained by standard questionnaire to analyze. We evaluated the distribution of the HCT values for middle-aged adults with or without cardiovascular risk factors. There were 548 males and 1,336 females in this study. The mean age of all subjects was 54.7 ± 6.7 years. There were 1,209 subjects with risk factors and 675 without risk factors.

RESULTS

The HCT levels in subjects with risk factors were higher than those without risk factors (P = 0.005). According to a simplified tool for evaluation of the 10-year risk of ischemic cardiovascular diseases (CVDs) in Chinese populations, all subjects were divided into four groups: the ultralow-risk group (1,367, 72.6%), low-risk group (232, 12.3%), intermediate-risk group (201, 10.7%), and high-risk/ultrahigh-risk group (84, 4.4%). Compared with HCT levels in the ultralow-risk group, significant differences were found in the low-risk, intermediate-risk, and high-risk/ultrahigh-risk groups (all P < 0.05).

CONCLUSION

Our results indicate that elevated HCT levels may be positively associated with cardiovascular risk factors. Thus, the combination of HCT values and cardiovascular risk factors may enable early diagnosis of CVDs.

BMI Is an Independent Preoperative Predictor of Intraoperative Transfusion and Postoperative Chest-Tube Output

Background An increasing obese population in the United States focuses attention on perioperative management of obese and overweight patients. Objective We sought to determine if obesity, determined by body mass index (BMI), was a preoperative indicator of bleeding in coronary artery bypass graft (CABG) surgery as measured by intraoperative packed red blood cell transfusion frequency and 24-hour chest-tube output amount. Methods A retrospective chart review examined 290 consecutive patients undergoing single-surgeon off-pump or on-pump CABG surgery between November 2003 and April 2009. Preoperative variables of age, gender, hematocrit, platelet count, and BMI, chest tube output during the immediate 24-hour postoperative period, and the type of procedure (on-pump vs. off-pump) were analyzed. Logistic regression analysis was used to evaluate the likelihood of intraoperative transfusion. Linear regression analysis was used to evaluate 24-hour chest-tube output. Results Preoperative variables that significantly increased the likelihood of intraoperative transfusions were older age and low hematocrit; a significant decrease in likelihood was found with male gender, overweight BMI, and off-pump procedures. Preoperative variables that significantly increased 24-hour chest-tube output were low hematocrit, high hematocrit, and low platelets while a significant decrease in output was seen with overweight BMI and obese BMI. Conclusion Overweight and obese BMI are significant independent predictors of decreased intraoperative transfusion and decreased postoperative blood loss.

Coronary artery bypass graft surgery: the past, present, and future of myocardial revascularisation

The development of the heart-lung machine ushered in the era of modern cardiac surgery. Coronary artery bypass graft surgery (CABG) remains the most common operation performed by cardiac surgeons today. From its infancy in the 1950s till today, CABG has undergone many developments both technically and clinically. Improvements in intraoperative technique and perioperative care have led to CABG being offered to a more broad patient profile with less complications and adverse events. Our review outlines the rich history and promising future of myocardial revascularization.

Predictors of blood transfusion in patients undergoing coronary artery bypass grafting surgery

OBJECTIVES

The aim of this retrospective study is to identify intraoperative patient's characteristics predicting the need for blood transfusion during CABG in our local cardiac surgical service.

METHODS

This study included 1835 consecutive patients, 1311 males and 524 females with mean age 58.8±9.9 years, undergoing coronary artery bypass grafting. Risk factors detected by univariate study were entered in a multivariate logistic regression model of the relationship between preoperative variables and blood transfusion.

RESULTS

Blood transfusion was used in 435 patients (29.9%). Univariate analysis identified hemoglobin, smoking, hypertension, sex, diabetes, BMI and use of cardiopulmonary bypass (CPB) as significant predictors. Multivariate analysis revealed hemoglobin (OR: 0.8; CI: 0.74-0.86; P<0.001), CPB use (OR: 12.2; CI: 8.2-18.1; P<0.001) and female gender (OR: 2.29; CI:1.72-3.04; P<0.001) as independent risk factors for blood transfusion.

CONCLUSIONS

The predictors of RBC transfusion after isolated CABG were performing CPB, preoperative hemoglobin and female gender. These factors can be used as a clinical tool to preserve blood bank resources without increasing patient's risk.

Risk Factors of Red Blood Cell Transfusion in Isolate off Pump Coronary Artery Bypass Surgery

BACKGROUND

Perioperative transfusion of red blood cell (RBC) may cause adverse effects. Bloodless-cardiac surgery has been spotlighted to avoid those problems. Off pump coronary artery bypass (OPCAB) surgery can decrease the transfusion. However, the risk factors of transfusions in OPCAB have not been investigated properly.

MATERIALS AND METHODS

One hundred and thirteen patients (male:female=35:78, mean age=66.7±9.9 years) who received isolated OPCAB were retrospectively analyzed from March 2006 to September 2007. The threshold of RBC transfusion was 28.0% of hematocrit. Bilateral internal thoracic arteries graft were used for 99 patients (87.6%). One hundred and three (91.1%) and 35 patients (31.5%) took aspirin and clopidogrel just before surgery.

RESULTS

Sixty-five patients (47.5%) received the RBC transfusion (mean 2.2±3.2 units). Mortality and major complications were not different between transfusion and no-transfusion group. But, ventilator support time, intensive care unit stay and hospitalization period had been reduced in no-transfusion group (p<0.05). In multivariate analysis, patients risk factors for RBC transfusion were preoperative low hematocrit (<37.5%) and clopidogrel medication. Surgical risk factors were longer graft harvesting time (>75 minutes) and total operation time (>5.5 hours, p<0.05).

CONCLUSION

We performed the transfusion according to transfusion guideline; over 40% cases could conduct the OPCAB without transfusion. There were no differences in major clinical results between transfusion and non-transfusion group. In addition, when used together with accurate understanding of transfusion risk factors, it is expected to increase the proportion of patients that do not undergo transfusions.

Individual surgeon's impact on the risk of re-exploration for excessive bleeding after coronary artery bypass surgery

OBJECTIVE

Excessive bleeding requiring re-exploration is a severe complication that may affect the outcome after coronary artery bypass grafting. The authors hypothesized that surgeon performance may contribute significantly to such a complication.

DESIGN

Retrospective.

SETTING

Tertiary referral center in a university hospital.

PARTICIPANTS

Two thousand one patients.

INTERVENTIONS

Isolated coronary artery bypass grafting.

RESULTS

Re-exploration for bleeding was performed in 113 patients (5.3%). Re-exploration was performed ≥3 days after surgery in 11 patients. The surgical site of bleeding was identified in 83 patients (73.5%). Rates of re-exploration for excessive bleeding ranged from 1.4% to 11.7% according to different surgeons (p < 0.0001). When adjusted for the additive European System for Cardiac Operative Risk Evaluation, re-exploration for bleeding was associated with increased risks of low-cardiac-output syndrome (odds ratio [OR] 2.239, 95% confidence interval [CI] 1.328-3.777), prolonged need for inotropes (OR 1.894, 95% CI 1.198-2.994), and an intensive care unit stay ≥5 days (OR 2.129, 95% CI 1.202-3.770). Logistic regression showed that an individual surgeon (p < 0.0001), preoperative body mass index <25 kg/m(2) (OR 2.733, 95% CI 2.145-3.481), and estimated glomerular filtration rate <30 mL/min/1.73 m(2) (OR 3.891, 95% CI 1.669-9.076) were independent predictors of re-exploration for excessive bleeding. An individual surgeon also was an independent predictor of a postoperative blood loss ≥1,600 mL.

CONCLUSIONS

An individual surgeon has a major impact on postoperative bleeding, and a meticulous surgical technique is expected to decrease significantly such a severe complication.