2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

Comprehensive perioperative blood management in patients undergoing elective bypass cardiac surgery: Benefit effect of health care education and systematic correction of iron deficiency and anemia on red blood cell transfusion

STUDY OBJECTIVE

The aim of this study was to investigate the efficacy of a two-step patient blood management (PBM) program in red blood cell (RBC) transfusion requirements among patients undergoing elective cardiopulmonary bypass (CPB) surgery.

DESIGN

Prospective, non-randomized, two-step protocol design.

SETTING

Cardiac surgery department of Clinique Pasteur, Toulouse, France.

PATIENTS

897 patients undergoing for elective CPB surgery.

INTERVENTIONS

We conducted a two-steps protocol: PBMe and PBMc. PBMe involved a short quality improvement program for health care workers, while PBMc introduced a systematic approach to pre- and postoperative correction of deficiencies, incorporating iron injections, oral vitamins, and erythropoiesis-stimulating agents.

MEASUREMENTS

The PBM program's effectiveness was evaluated through comparison with a pre-PBM retrospective cohort after propensity score matching. The primary objective was the proportion of patients requiring RBC transfusions during their hospital stay. Secondary objectives were also analyzed.

MAIN RESULTS

After matching, 343 patients were included in each group. Primary outcomes were observed in 35.7% (pre-PBM), 26.7% (PBMe), and 21.1% (PBMc) of patients, resulting in a significant reduction (40.6%) in the overall RBC transfusion rate. Both the PBMe and PBMc groups exhibited significantly lower risks of RBC transfusion compared to the pre-PBM group, with adjusted odds ratios of 0.59 [95% CI 0.44-0.79] and 0.44 [95% CI 0.32-0.60], respectively. Secondary endpoints included reductions in transfusions exceeding 2 units, total RBC units transfused, administration of allogeneic blood products, and total bleeding volume recorded on Day 1. There were no significant differences noted in mortality rates or the duration of hospital stays.

CONCLUSIONS

This study suggests that health care education and systematic deficiency correction are associated with reduced RBC transfusion rates in elective CPB surgery. However, further randomized, controlled studies are needed to validate these findings and refine their clinical application.

Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial

BACKGROUND

Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain.

METHODS

This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions.

RESULTS

The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications.

CONCLUSION

The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB.

STUDY REGISTRATION

This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Intraoperative haemoadsorption for antithrombotic drug removal during cardiac surgery: initial report of the international safe and timely antithrombotic removal (STAR) registry

Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y12 inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81% male) operated at a mean time of 33.2 h from the last P2Y12 inhibitor dose with a mean CPB duration of 117.1 ± 62.0 min. Group 2 included 51 patients (68.4 ± 9.4years, 53% male), operated at a mean time of 44.6 h after the last DOAC dose, with a CPB duration of 128.6 ± 48.4 min. In Group 1, 15 patients experienced a BARC-4 bleeding event (13%), including 3 reoperations (2.6%). The mean 24-hour CTD was 651 ± 407mL. In Group 2, 8 patients experienced a BARC-4 bleeding event (16%) including 4 reoperations (7.8%). The mean CTD was 675 ± 363mL. This initial report of the ongoing STAR registry shows that the intraoperative use of a haemoadsorption device is simple and safe, and may potentially mitigate the expected high bleeding risk of patients on antithrombotic drugs undergoing cardiac surgery before completion of the recommended washout period.Clinical registration number: ClinicalTrials.gov identifier: NCT05077124.

Improvement of Transfusion Practice in Cardiothoracic Surgery Through Implementing a Patient Blood Management Program

Background

In this study, we examined the impact of a patient blood management (PBM) program on red blood cell (RBC) transfusion practices in cardiothoracic surgery.

Methods

The PBM program had 3 components: monitoring transfusions through an order communication system checklist, educating the medical team about PBM, and providing feedback to ordering physicians on the appropriateness of transfusion. The retrospective analysis examined changes in the hemoglobin levels triggering transfusion and the proportions of appropriate RBC transfusions before, during, and after PBM implementation. Further analysis was focused on patients undergoing cardiac surgery, with outcomes including 30-day mortality, durations of intensive care unit and hospital stays, and rates of pneumonia, sepsis, and wound complications.

Results

The study included 2,802 patients admitted for cardiothoracic surgery. After the implementation of PBM, a significant decrease was observed in the hemoglobin threshold for RBC transfusion. This threshold dropped from 8.7 g/dL before PBM to 8.3 g/dL during the PBM education phase and 8.0 g/dL during the PBM feedback period. Additionally, the proportion of appropriate RBC transfusions increased markedly, from 23.9% before PBM to 34.9% and 58.2% during the education and feedback phases, respectively. Among the 381 patients who underwent cardiac surgery, a significant reduction was noted in the length of hospitalization over time (p<0.001). However, other clinical outcomes displayed no significant differences.

Conclusion

PBM implementation effectively reduced the hemoglobin threshold for RBC transfusion and increased the rate of appropriate transfusion in cardiothoracic surgery. Although transfusion practices improved, clinical outcomes were comparable to those observed before PBM implementation.

Platelet inhibitor withdrawal and outcomes after coronary artery surgery: an individual patient data meta-analysis

OBJECTIVES

To evaluate the association between guideline-conforming as compared to shorter than recommended withdrawal period of P2Y12 receptor inhibitors prior to isolated on-pump coronary artery bypass grafting (CABG) and the incidence of severe bleeding and ischaemic events. Randomized controlled trials are lacking in this field.

METHODS

We searched PUBMED, Embase and other suitable databases for studies including patients on P2Y12 receptor inhibitors undergoing isolated CABG and reporting bleeding and postoperative ischaemic events from 2013 to March 2024. The primary outcome was incidence of Bleeding Academic Research Consortium type 4 (BARC-4) bleeding defined as any of the following: perioperative intracranial bleeding, reoperation for bleeding, transfusion of ≥5 units of red blood cells, chest tube output of ≥2 l. The secondary outcome was postoperative ischaemic events according to the Academic Research Consortium 2 Consensus Document. Patient-level data provided by each observational trial were synthesized into a single dataset and analysed using a 2-stage IPD-MA.

RESULTS

Individual data of 4837 patients from 7 observational studies were synthesized. BARC-4 bleeding, 30-day mortality and postoperative ischaemic events occurred in 20%, 2.6% and 5.2% of patients. After adjusting for EuroSCORE II and cardiopulmonary bypass time, guideline-conforming withdrawal was associated with decreased BARC-4 bleeding risk in patients on clopidogrel [adjusted odds ratio (OR) 0.48; 95% confidence intervals (CI) 0.28-0.81; P = 0.006] and a trend towards decreased risk in patients on ticagrelor (adjusted OR 0.48; 95% CI 0.22-1.05; P = 0.067). Guideline-conforming withdrawal was not significantly associated with 30-day mortality risk (clopidogrel: adjusted OR 0.70; 95% CI 0.30-1.61; ticagrelor: adjusted OR 0.89; 95% CI 0.37-2.18) but with decreased risk of postoperative ischaemic events in patients on clopidogrel (clopidogrel: adjusted OR 0.50; 95% CI 0.30-0.82; ticagrelor: adjusted OR 0.78; 95% CI 0.45-1.37). BARC-4 bleeding was associated with 30-day mortality risk (adjusted OR 4.76; 95% CI 2.67-8.47; P < 0.001).

CONCLUSIONS

Guideline-conforming preoperative withdrawal of ticagrelor and clopidogrel was associated with a 50% reduced BARC-4 bleeding risk when corrected for EuroSCORE II and cardiopulmonary bypass time but was not associated with increased risk of 30-day mortality or postoperative ischaemic events.

Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

OBJECTIVES

To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference.

DATA SOURCES

A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021.

STUDY SELECTION

Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs).

DATA EXTRACTION

Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form.

MEASUREMENTS AND MAIN RESULTS

Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented.

CONCLUSIONS

Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.

The Role of Viscoelastic Testing in Assessing Hemostasis: A Challenge to Standard Laboratory Assays?

Viscoelastic testing is increasingly being used in clinical and research settings to assess hemostasis. Indeed, there are potential situations in which viscoelastic testing is reportedly superior to standard routine laboratory testing for hemostasis. We report the current testing platforms and terminology, as well as providing a concise narrative review of the published evidence to guide its use in various clinical settings. Notably, there is increasing evidence of the potential utility of viscoelastic testing for assessment of direct oral anticoagulants, and bleeding associated with chronic liver disease, orthotopic liver transplantation, cardiac surgery, trauma, obstetrics and pediatrics.

Effect of Preoperative Recombinant Human Erythropoietin on the Need for Blood Transfusion and Surgical Outcomes in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

This study aimed to examine the value of preoperative recombinant human erythropoietin (rhEPO) administration to adults undergoing elective cardiac surgery. Databases were searched for randomized controlled trials (RCTs) comparing rhEPO plus standard treatment versus standard treatment only. Primary outcomes were the need for and volume of homologous blood transfusion (HBT). Secondary outcomes were the lengths of intensive care unit (ICU) and hospital stay and the incidence of major adverse events. There was very low certainty that rhEPO is associated with a reduction in the need for HBT, with a number needed to treat of 5.6 (95% confidence interval [CI], 3.9-12.5), and low certainty that it is associated with a moderate reduction in HBT volume (Hedges g = -0.55; 95% CI, -0.79 to -0.32). Meta-regression revealed that studies with a higher proportion of females or older patients demonstrated less benefit of rhEPO in terms of reduced consumption of HBT. Trial sequential analysis showed that rhEPO was superior to standard treatment only for reducing the need for and volume of HBT. Regarding secondary outcomes, there was moderate certainty that rhEPO is associated with a limited reduction in the length of ICU (Hedges g = -0.10; 95% CI, -0.19 to -0.01) and hospital stay (Hedges g = -0.13; 95% CI = -0.25 to -0.02), and low certainty for increased risk of myocardial infarction, with a number needed to harm of 36.1 (95% CI, 17.9-127.4). More well-designed, adequately powered RCTs are needed to draw conclusions regarding the value of rhEPO.

Improved outcome with individualised antifibrinolytic therapy: what is the evidence?

Viscoelastic haemostatic testing (VHT) has been used to determine hyperfibrinolysis and hypofibrinolysis. When modified by addition of tissue plasminogen activator (tPA), VHT has been suggested to assess responses to antifibrinolytic therapy and to estimate the concentration of tranexamic acid in patients undergoing cardiac surgery. Despite some evidence that tPA-modified VHT might allow individualisation of antifibrinolytic therapy, further studies are warranted to prove its clinical benefit for postsurgical bleeding, transfusion of blood products, and thromboembolic events.

Activated clotting time value as an independent predictor of postoperative bleeding and transfusion

OBJECTIVES

Activated clotting time (ACT) is commonly used to monitor anticoagulation during cardiac surgeries. Final ACT values may be essential to predict postoperative bleeding and transfusions, although ideal values remain unknown. Our aim was to evaluate the utility of ACT as a predictor of postoperative bleeding and transfusion use.

METHODS

Retrospective study (722 patients) submitted to surgery between July 2018-October 2021. We compared patients with final ACT < basal ACT and final ACT ≥ basal ACT and final ACT < 140 s with ≥140 s. Continuous variables were analysed with the Wilcoxon rank-sum test; categorical variables using Chi-square or Fisher's exact test. A linear mixed regression model was used to analyse bleeding in patients with final ACT < 140 and ≥140. Independent variables were analysed with binary logistic regression models to investigate their association with bleeding and transfusion.

RESULTS

Patients with final ACT ≥ 140 s presented higher postoperative bleeding than final ACT < 140 s at 12 h (P = 0.006) and 24 h (**P = 0.004). Cardiopulmonary bypass (CPB) time [odds ratio (OR) 1.009, 1.002-1.015, 95% confidence interval (CI)] and masculine sex (OR 2.842,1.721-4.821, 95% CI) were significant predictors of bleeding. Patients with final ACT ≥ 140 s had higher risk of UT (OR 1.81, 1.13-2.89, 95% CI; P = 0.0104), compared to final ACT < 140 s. CPB time (OR 1.019,1.012-1.026, 95% CI) and final ACT (OR 1.021,1.010-1.032, 95% CI) were significant predictors of transfusion. Female sex was a predictor of use of transfusion, with a probability for use of 27.23% (21.84-33.39%, 95% CI) in elective surgeries, and 60.38% (37.65-79.36%, 95% CI) in urgent surgeries, higher than in males.

CONCLUSIONS

Final ACT has a good predictive value for the use of transfusion. Final ACT ≥ 140 s correlates with higher risk of transfusion and increased bleeding. The risk of bleeding and transfusion is higher with longer periods of CPB. Males have a higher risk of bleeding, but females have a higher risk of transfusion.

Clues of incomplete reversal of heparin in cardiac surgery

OBJECTIVES

In our center, an unusual rate of patients had abnormalities of hemostasis in immediate postoperative period of cardiac surgery. Our objectives were to identify the cause of these sudden hemostasis abnormalities and to evaluate the performances of point of care coagulation testing.

METHODS

In this prospective and descriptive study, we included 33 consecutive patients undergoing elective cardiac surgery for 1 month. Heparin-induced anticoagulation and calculation of the protamine dose were tested by the Hemostasis Management System Plus device (Medtronic, Minneapolis, MN, USA). Fifteen minutes after the end of the protamine infusion, activated clotting time (ACT), activated partial thromboplastin time and anti Xa activity were measured. In case of unusual clinical bleeding, a Quantra analysis (Stago, HemoSonics LLC, Charlottesville, VA) was added.

RESULTS

Residual antiXa activity >0.2 IU/mL after neutralization was present in 44% of patients. Our investigation concluded incomplete heparin reversal. There was no association between cellular reinfusate and the presence of heparin. The unusual rate of hemostasis abnormalities was explained by a less efficient protamine reversal of heparin. ACT and Clot Time Ratio (CTR, Quantra system) correlated with AntiXa with Spearman's coefficients of 0.85 (p < .0001) and 0.95 (p = .0012), respectively. About ACT, a threshold of 150 seconds had a sensitivity of 85% [58-97] and a specificity of 85% [58-97%] for detection of AntiXa>0.2. For CTR, a threshold of 1.4 had a sensitivity of 67% [30-94] and a specificity of 100% [18-100].

CONCLUSION

The use of point of care coagulation testing is effective in detecting incomplete reversal of heparin.

A Case Report of Pulmonary Embolectomy Under Cardiopulmonary Bypass in a Patient with Intracranial Hemorrhage and History of Heparin-Induced Thrombocytopenia

Pulmonary embolism is a common complication after intracranial hemorrhage. As thrombolysis is contraindicated in this situation, surgical pulmonary embolectomy may be indicated in case of high-risk pulmonary embolism but requires transient anticoagulation with heparin during cardiopulmonary bypass. We report the case of a patient with a history of heparin-induced thrombocytopenia who presented with a high-risk pulmonary embolism 10 days after the spontaneous onset of a voluminous intracerebral hematoma. Despite high doses of heparin required to run the cardiopulmonary bypass and subsequent anticoagulation by danaparoid sodium, the brain hematoma remained stable and the patient was discharged without complications 30 days after surgery.

Preoperative hypocoagulative state is an independent risk factor for wound complications and infection in gender-affirming bottom surgeries

BACKGROUND

Bottom gender affirmation surgery (GAS) involves the risks of bleeding and associated complications. Effective preoperative blood management is paramount across surgical disciplines with international normalized ratio (INR)≤1.5 advised prior to certain surgeries. This study aimed to examine the proportion of patients who were hypocoagulative before they underwent bottom GAS and assess the influence of hypocoagulability on their 30-day post-operative outcomes.

METHOD

A retrospective study on female-to-male (FtM) and male-to-female (MtF) bottom GAS was performed based on American college of surgeons national surgical quality improvement program (ACS-NSQIP) database from 2005 to 2021. Patients with hypocoagulation were identified when PTT> 60 s, PT > 30 s, and/or INR> 2. Multivariable logistic regression was used to compare the 30-day perioperative outcomes between patients with hypocoagulation and controls.

RESULTS

In this study, 380 patients (182 FtM, 198 MtF) with hypocoagulation and 1176 controls (886 FtM, 310 MtF) were included. Mortality and organ system complications were infrequent in both groups. Patients with hypocoagulation had higher wound complication rates (13.68% vs. 2.64%, aOR 2.858, p < 0.01), especially wound dehiscence (10.00% vs. 0.60%, aOR 4.424, p < 0.01) and organ space infection rates (2.11% vs. 0.26%, aOR 12.77, p < 0.01). Additionally, patients with hypocoagulation had higher sepsis (0.79% vs. 0.09%, aOR 15.508, p = 0.04) and readmission rates (4.74% vs. 2.47%, aOR 1.919, p = 0.03), but lower rates of discharge not to home (7.92% vs. 25.38%, aOR 0.324, p < 0.01).

CONCLUSION

Preoperative hypocoagulative state is observed in approximately a quarter of the patients undergoing bottom GAS and is an independent risk factor for increased risks of 30-day wound complications and infections. Therefore, meticulous monitoring of preoperative hemostasis and implementing hemostasis control before surgery may be necessary. Thus, it may be advisable to discontinue oral anticoagulants before the surgery.

Implementation of Patient Blood Management in Orthotopic Heart Transplants: A Single Centre Retrospective Observational Review

BACKGROUND

Blood transfusion in the perioperative cardiothoracic setting has accepted risks including deep sternal wound infection, increased intensive care unit length of stay, lung injury, and cost. It has an immunomodulatory effect which may cause allo-immunisation. This may influence long-term survival through immune-mediated factors. Targeting coagulation defects to reduce unnecessary or inappropriate transfusions may reduce these complications.

METHODS

In 2012, an institution-wide patient blood management evidence-based algorithmic bleeding management protocol was implemented at The Prince Charles Hospital, Brisbane, Australia. The benefit of this has been previously reported in our lung transplant and cardiac surgery (excluding transplants) cohorts. This study aimed to investigate the effect of this on our orthotopic heart transplant recipients.

RESULTS

After the implementation of the protocol, despite no difference in preoperative haemoglobin levels and higher risk patients (EuroSCORE 20 vs 26; p=0.013), the use of packed red blood cells (13.0 U vs 4.4 U; p=0.046) was significantly lower postoperatively and fresh frozen plasma was significantly lower both intra- and postoperatively (7.4 U vs 0.6 U; p<0.001, and 3.3 U vs 0.6 U; p=0.011 respectively). Concurrently, the use of prothrombin complex concentrate (33% vs 78%; p<0.001) and desmopressin (5% vs 22%; p=0.0028) was significantly higher in the post-protocol group, while there was less use of recombinant factor VIIa (15% vs 4%; p=0.058). Intraoperative units of cryoprecipitate also rose from 0.9 to 2.0 (p=0.006).

CONCLUSIONS

We have demonstrated that a targeted patient blood management protocol with point-of-care testing for heart transplant recipients is correlated with fewer blood products used postoperatively, with some increase in haemostatic products and no evidence of increased adverse events.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Effect of blood conservation protocol on the utilisation of blood and outcome of patients undergoing open heart surgery

INTRODUCTION

Cardiac surgery is fraught with increased consumption of blood and blood products. Various strategies for blood conservation have been described. Our aim was to study the impact of a structured blood conservation protocol (BCP) on the utilization of blood and patient outcome.

METHODS

Retrospective analysis of prospectively collected data comparing adult patients undergoing open heart surgery with BCP with those undergoing surgery without BCP. The primary objective was to compare the amount of blood utilized and the hematocrit at discharge. The secondary objective was to compare the parameters of patient outcomes. The level of significance was set at 0.05.

RESULTS

The proportion of patients requiring transfusion (19.1% [9/47] vs 58.9% [33/56]; p < 0.001) and the quantity of blood transfused (12 units vs 45 units; p 0.003) in the BCP group was significantly lower. Interestingly, the hematocrit level at discharge was comparable between the groups (30.9 (4.8) versus 31.8 (2.4), p-0.671). The average cost incurred for transfusing blood in the BCP group was ₹ 370.2 as compared to ₹1165.1 in the other (p < 0.001). BCP reduced the odds of overall blood transfusion by 79.8% (OR 0.202 (0.084-0.485); p < 0.001) and intraoperative blood transfusion by 95.3% (OR 0.047 (0.010-0.213); p < 0.001). The morbidity and mortality were comparable between the groups.

CONCLUSION

Implementing a structured blood conservation protocol in patients undergoing open heart surgery significantly reduces the need for blood transfusion. It also has a promising impact on patient recovery after surgery and significant positive cost implications.

A Comprehensive Patient Blood Management Program During Cardiopulmonary Bypass in Patients Over 60 Years of Age

Purpose

There is currently no consensus on the most appropriate blood transfusion strategy for older adults undergoing cardiovascular surgery. We aimed to investigate the potential benefits of the patient blood management (PBM) program specifically for advanced age patients, and to evaluate the relationship of age and PBM in cardiovascular surgery.

Patients and Methods

We collected data from patients over 60 years old who underwent on-pump cardiovascular surgery. We compared transfusion and clinical outcomes between the pre-PBM and post-PBM groups using a propensity score matching method. Then, we conducted a subgroup analysis within the original cohort, specifically focusing on patients aged of 75 and above with multivariable adjusted models.

Results

Data of 9703 older adults were analyzed. Red blood cell (RBC) transfusion rates during cardiopulmonary bypass (CPB) (31.6% vs 13.1%, P<0.001), during the operation (50.8% vs 39.0%, P<0.001) and after the operation (5.6% vs 3.1%, P<0.001) were significantly reduced, and mortality and the risk of some adverse events were also reduced after the PBM. Subgroup analysis showed that there was no interaction between age and PBM, and advanced age (over age 75) did not modify the effect of PBM program in reducing RBC transfusion (Pinteraction=0.245), on mortality (Pinteration=0.829) and on certain complications.

Conclusion

The comprehensive PBM program could reduce RBC transfusion without adverse outcomes in older patients undergoing CPB. Even patients over age 75 may benefit from a more stringent transfusion indication. Comprehensive blood conservation measures should be applied to optimize the blood management for older patients.

Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis

BACKGROUND

Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated.

STUDY DESIGN

Retrospective cohort study.

METHODS

We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8).

RESULTS

We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate.

CONCLUSION

High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.

Prediction of intraoperative red blood cell transfusion in valve replacement surgery: machine learning algorithm development based on non-anemic cohort

Background

Our study aimed to develop machine learning algorithms capable of predicting red blood cell (RBC) transfusion during valve replacement surgery based on a preoperative dataset of the non-anemic cohort.

Methods

A total of 423 patients who underwent valvular replacement surgery from January 2015 to December 2020 were enrolled. A comprehensive database that incorporated demographic characteristics, clinical conditions, and results of preoperative biochemistry tests was used for establishing the models. A range of machine learning algorithms were employed, including decision tree, random forest, extreme gradient boosting (XGBoost), categorical boosting (CatBoost), support vector classifier and logistic regression (LR). Subsequently, the area under the receiver operating characteristic curve (AUC), accuracy, recall, precision, and F1 score were used to determine the predictive capability of the algorithms. Furthermore, we utilized SHapley Additive exPlanation (SHAP) values to explain the optimal prediction model.

Results

The enrolled patients were randomly divided into training set and testing set according to the 8:2 ratio. There were 16 important features identified by Sequential Backward Selection for model establishment. The top 5 most influential features in the RF importance matrix plot were hematocrit, hemoglobin, ALT, fibrinogen, and ferritin. The optimal prediction model was CatBoost algorithm, exhibiting the highest AUC (0.752, 95% CI: 0.662-0.780), which also got relatively high F1 score (0.695). The CatBoost algorithm also showed superior performance over the LR model with the AUC (0.666, 95% CI: 0.534-0.697). The SHAP summary plot and the SHAP dependence plot were used to visually illustrate the positive or negative effects of the selected features attributed to the CatBoost model.

Conclusions

This study established a series of prediction models to enhance risk assessment of intraoperative RBC transfusion during valve replacement in no-anemic patients. The identified important predictors may provide effective preoperative interventions.

Frailty, periinterventional complications and outcome in patients undergoing percutaneous mitral and tricuspid valve repair

BACKGROUND

Frailty is common in elderly and multimorbid patients and associated with increased vulnerability to stressors.

METHODS

In a single centre study frailty according to Fried criteria was assessed in consecutive patients before transcatheter mitral and tricuspid valve repair. Postprocedural infections, blood transfusion and bleeding and renal failure were retrospectively assessed from records. Median follow-up time for survival was 560 days (IQR: 363 to 730 days).

RESULTS

90% of 626 patients underwent mitral valve repair, 5% tricuspid valve repair, and 5% simultaneous mitral and tricuspid valve repair. 47% were classified as frail. Frailty was associated with a significantly increased frequency of bleeding (16 vs 10%; p = 0.016), blood transfusions (9 vs 3%; p =  < 0.001) and infections (18 vs 10%; p = 0.006), but not with acute kidney injury (20 vs 20%; p = 1.00). Bleeding and infections were associated with longer hospital stays, with a more pronounced effect in frail patients (interaction test p < 0.05, additional 3.2 and 4.1 days in frail patients, respectively). Adjustment for the occurrence of complications did not attenuate the increased risk of mortality associated with frailty (HR 2.24 [95% CI 1.62-3.10]; p < 0.001).

CONCLUSIONS

Bleeding complications and infections were more frequent in frail patients undergoing transcatheter mitral and tricuspid valve repair and partly explained the longer hospital stay. Albeit some of the complications were associated with higher long-term mortality, this did not explain the strong association between frailty and mortality. Further research is warranted to explore interventions targeting periprocedural complications to improve outcomes in this vulnerable population.

[Update on point-of-care-based coagulation treatment : Systems, reagents, device-specific treatment algorithms]

Viscoelastic test (VET) procedures suitable for point-of-care (POC) testing are in widespread clinical use. Due to the expanded range of available devices and in particular due to the development of new test approaches and methods, the authors believe that an update of the current treatment algorithms is necessary. The aim of this article is to provide an overview of the currently available VET devices and the associated reagents. In addition, two treatment algorithms for the VET devices most commonly used in German-speaking countries are presented.

Direct Oral Anticoagulant Use Early After Cardiac Surgery: A Retrospective Cohort Study

Background

There is limited literature guiding the prescribing of direct oral anticoagulants (DOACs) early after cardiac surgery as this population has been excluded from landmark randomized controlled trials. This study aims to determine the rate of in-hospital DOAC use compared with warfarin early after cardiac surgery, evaluate factors associated with DOAC use, determine difference in postoperative length of stay, and characterize bleeding events.

Methods

A retrospective cohort study was conducted in adult patients with indications for anticoagulation and receiving either a DOAC or warfarin after cardiac surgery during their index hospitalization. Patients were excluded if they had any contraindications to DOAC use. The primary outcome was the proportion of patients discharged on a DOAC compared with warfarin.

Results

Of included 210 patients, 30% received DOACs and 70% received warfarin on discharge. The most common DOAC used was apixaban (74.6%), and median postoperative day of initiation was 5 days. Patients receiving DOACs were older (70.8 vs 68.0 years), had less valvular heart disease (38.1% vs 63.9%), were more likely to be on DOACs preoperatively (50.8% vs 31.3%), and were more likely to have undergone coronary artery bypass graft alone (54.0% vs 24.5%) compared with those on warfarin. Postoperative length of stay (7 vs 9 days; P = 0.59) and in-hospital bleeding (1.6% vs 2.0%; P = 1.00) did not differ between DOAC and warfarin groups.

Conclusions

At a quaternary referral centre for cardiac surgery, DOACs were used in approximately one-third of patients with an indication for anticoagulation early after cardiac surgery.

Impact of Additional Administration of von Willebrand Factor Concentrates to Thrombocyte Transfusion in Perioperative Bleeding in Cardiac Surgery

Background

Von Willebrand factor (vWF) is an important part of blood coagulation since it binds platelets to each other and to endothelial cells. In traumatic and surgical haemorrhage, both blood cells and plasmatic factors are consumed, leading to consumption coagulopathy and fluid resuscitation. This often results in large amounts of crystalloids and blood products being infused. Additional administration of vWF complex and platelets might mitigate this problem. We hypothesize that administration of vWF concentrate additionally to platelet concentrates reduces blood loss and the amount of blood products (platelets, red blood cells [RBC], fresh frozen plasma [FFP]) administered.

Methods

We conducted a monocentric 6-year retrospective data analysis of cardiac surgery patients. Included were all patients receiving platelet concentrates within 48 h postoperatively. Patients who additionally received vWF concentrates were allocated to the intervention group and all others to the control group. Groups were compared in mixed regression models correcting for known confounders, based on nearest neighbour propensity score matching. Primary endpoints were loss of blood (day one and two) and amount of needed blood products on day one and two (platelets, RBC, FFP). Secondary endpoints were intensive care unit (ICU) and in-hospital length of stay, ICU and in-hospital mortality, and absolute difference of platelet counts before and after treatment.

Results

Of 497 patients analysed, 168 (34%) received vWF concentrates. 121 patients in both groups were considered for nearest neighbour matching. Patients receiving additional vWF were more likely to receive more blood products (RBC, FFP, platelets) in the first 24 h after surgery and had around 200 mL more blood loss at the same time.

Conclusion

In this retrospective analysis, no benefit in additional administration of vWF to platelet concentrates on perioperative blood loss, transfusion requirement (platelets, RBC, FFP), length of stay, and mortality could be found. These findings should be verified in a prospective randomized controlled clinical trial (www.clinicaltrials.gov identifier NCT04555785).

Survey of the Impact of Decision Support in Preoperative Management of Anemia (i-Anemia): Survey Study

BACKGROUND

Major surgery on patients with anemia has demonstrated an increased risk of perioperative blood transfusions and postoperative morbidity and mortality. Recent studies have shown that integrating preoperative anemia treatment as a component of perioperative blood management may reduce blood product utilization and improve outcomes in both cardiac and noncardiac surgery. However, outpatient management of anemia falls outside of daily practice for most anesthesiologists and is probably weakly understood.

OBJECTIVE

We conducted a simulated case survey with anesthesiologists to accomplish the following aims: (1) evaluate the baseline knowledge of the preoperative optimization of anemia and (2) determine the impact of real-time clinical decision support on anemia management.

METHODS

We sent a digital survey (i-Anemia) to members of the French Society of Anaesthesia and Critical Care. The i-Anemia survey contained 7 simulated case vignettes, each describing a patient's brief clinical history and containing up to 3 multiple-choice questions related to preoperative anemia management (12 questions in total). The cases concerned potential situations of preoperative anemia and were created and validated with a committee of patient blood management experts. Correct answers were determined by the current guidelines or by expert consensus. Eligible participants were randomly assigned to control or decision support groups. In the decision support group, the primary outcome measured was the correct response rate.

RESULTS

Overall, 1123 participants were enrolled and randomly divided into control (n=568) and decision support (n=555) groups. Among them, 763 participants fully responded to the survey. We obtained a complete response rate of 65.6% (n=364) in the group receiving cognitive aid and 70.2% (n=399) in the group without assistance. The mean duration of response was 10.2 (SD 6.8) minutes versus 7.8 (SD 5) minutes for the decision support and control groups, respectively (P<.001). The score significantly improved with cognitive aid (mean 10.3 out of 12, SD 2.1) in comparison to standard care (mean 6.2 out of 12, SD 2.1; P<.001).

CONCLUSIONS

Management strategies to optimize preoperative anemia are not fully known and applied by anesthesiologists in daily practice despite their clinical importance. However, adding a decision support tool can significantly improve patient care by reminding practitioners of current recommendations.

The Year in Coagulation and Transfusion: Selected Highlights from 2022

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

Perioperative hemostatic management of patients with type A aortic dissection

Coagulopathy is common in patients undergoing thoracic aortic repair for Stanford type A aortic dissection. Non-critical administration of blood products may adversely affect the outcome. It is therefore important to be familiar with the pathologic conditions that lead to coagulopathy in complex cardiac surgery. Adequate care of these patients includes the collection of the medical history regarding the use of antithrombotic and anticoagulant drugs, and a sophisticated diagnosis of the coagulopathy with viscoelastic testing and subsequently adapted coagulation therapy with labile and stable blood products. In addition to the above-mentioned measures, intraoperative blood conservation measures as well as good interdisciplinary coordination and communication contribute to a successful hemostatic management strategy.

Viscoelastic Testing Methods

Viscoelastic testing methods examine the real-time formation of a clot in a whole blood sample, and include thromboelastography (TEG), rotational thromboelastometry (ROTEM), and several other testing platforms. They allow for concurrent assessment of multiple aspects of clotting, including plasmatic coagulation factors, platelets, fibrinogen, and the fibrinolytic pathway. This testing is rapid and may be performed at the point-of-care, allowing for prompt identification of coagulopathies to guide focused and rational administration of blood products as well as the identification of anticoagulant effect. With recent industry progression towards user-friendly, cartridge-based, portable instruments, viscoelastic testing has emerged in the 21st century as a powerful tool to guide blood transfusions in the bleeding patient, and to identify and treat both bleeding and thrombotic conditions in many operative settings, including trauma surgery, liver transplant surgery, cardiac surgery, and obstetrics. In these settings, the use of transfusion algorithms guided by viscoelastic testing data has resulted in widespread improvements in patient blood management as well as modest improvements in select patient outcomes. To address the increasingly wide adoption of viscoelastic methods and the growing number of medical and laboratory personnel tasked with implementing, performing, and interpreting these methods, this chapter provides an overview of the history, physiology, and technology behind viscoelastic testing, as well as a practical review of its clinical utility and current evidence supporting its use. Also included is a review of testing limitations and the contextual role played by viscoelastic methods among all coagulation laboratory testing.

Real-World Experience with a Human Fibrinogen Concentrate: Clinical Data from Adult and Pediatric Patients Requiring Fibrinogen for Bleeding Control and Prevention

Human fibrinogen concentrate (Fibryga) received temporary approval for fibrinogen replacement therapy in France (2017), with subsequent full approval for congenital and acquired hypofibrinogenemia. We evaluated real-world use for on-demand treatment of bleeding and prophylaxis to enhance our knowledge on fibrinogen concentrate as an option for fibrinogen replacement. Data were retrospectively collected from adult and pediatric patients with fibrinogen deficiency. The primary end point was indication for fibrinogen concentrate use; the secondary end point was treatment success for on-demand treatment/perioperative prophylaxis. The study included 150 adult (median age, 62 years; range, 18-94 years) and 50 pediatric (median age, 3 years; range, 0.01-17 years) patients with acquired fibrinogen deficiency. Fibrinogen concentrate was administered to 47.3% for nonsurgical bleeding, 22.7% for surgical bleeding, and 30.0% for perioperative prophylaxis in adult patients, and to 4.0% for surgical bleeding and 96.0% for perioperative prophylaxis in pediatric patients. Cardiac surgeries accounted for 79.5%/75.0% perioperative prophylaxis and 82.4%/100.0% surgical bleeding cases in adult/pediatric patients, respectively. The mean ± standard deviation (SD, median) total fibrinogen doses were 3.06 ± 1.69 g (32.61 mg/kg), 2.09 ± 1.36 g (22.99 mg/kg), and 2.36 ± 1.25 g (29.67 mg/kg) for adult nonsurgical bleeding, surgical bleeding, and perioperative prophylaxis, respectively; doses of 0.75 ± 0.35 g (47.64 mg/kg) and 0.83 ± 0.62 g (55.56 mg/kg) were used for pediatric surgical bleeding and perioperative prophylaxis, respectively. Treatment success was 85.7%/97.1/93.3% in adults and 50.0%/87.5% in pediatrics for nonsurgical bleeding (adults only), surgical bleeding, and perioperative prophylaxis, respectively. Fibrinogen concentrate demonstrated favorable effectiveness and safety across the age groups. This study contributes to evidence supporting fibrinogen concentrate for bleeding control/prevention in real-world clinical practice, particularly for patients with acquired fibrinogen deficiency.

Impact of perfusion method on perioperative red blood cell transfusions and new-onset postoperative atrial fibrillation in mitral valve surgery patients

INTRODUCTION

Red blood cell (RBC) transfusions are common in cardiac surgery and reportedly associated with increased mortality and morbidity, including increased risk of postoperative new-onset atrial fibrillation (NOAF). The aim of this study was to compare minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC) in terms of RBC transfusions and the incidence of NOAF in mitral valve surgery.

METHODS

The study population consisted of 89 MiECC and 169 CECC patients undergoing mitral valve surgery as an isolated procedure (80.6% of the patients) or in combination with coronary artery bypass grafting (19.4% of patients). 79.4% of the patients were male and the mean age was 62.1 years.

RESULTS

30.0% of patients aged < 65 years and 48.1% of patients aged ≥ 65 years needed RBC transfusion. The overall need for RBC transfusions did not differ between the treatment groups. Among patients < 65 years of age transfusions of ≥ 3 units were less frequent in MiECC than in CECC patients (OR 0.31, 95% CI 0.10-0.98, p = 0.045). The overall incidence of NOAF was 41.8% with no significant difference between MiECC and CECC groups. Red blood cell transfusions were associated with an increased risk of NOAF in an unadjusted analysis but not after adjustment for age and sex (OR 1.25, 95% CI 0.64-2.43, p = 0.515).

CONCLUSIONS

In mitral valve surgery MiECC compared to CECC was associated with less need of RBC units and platelets, particularly in patients aged < 65 years. Use of RBC transfusions was associated with increased risk of NOAF significantly only in unadjusted analysis.

Basic Principles of Rotational Thromboelastometry (ROTEM®) and the Role of ROTEM-Guided Fibrinogen Replacement Therapy in the Management of Coagulopathies

Rotational thromboelastometry (ROTEM) is a viscoelastic method, which provides a graphical and numerical representation of induced hemostasis in whole blood samples. Its ability to quickly assess the state of hemostasis is used in the management of bleeding from a variety of causes. The separate activation of particular parts of hemocoagulation in INTEM, EXTEM, and FIBTEM tests allows for a more comprehensive and faster evaluation of the missing component of hemostasis followed by targeted therapy. One of the most common cause of coagulopathy is trauma-induced coagulopathy. Fibrinogen replacement therapy by ROTEM allows for the use of a standard dosage of fibrinogen, which has been shown to be successful in preventing dilutional coagulopathy following colloid and crystalloid replacement and excessive amount of allogeneic blood transfusions. The best reflection of fibrinogen activity is observed in the FIBTEM assay, where fibrinogen replacement therapy is recommended at an MCF (maximum clot firmness) of FIBTEM < 10 mm and FIBTEM A10 < 7 mm. ROTEM also plays an important role in the diagnostic and management of inherited fibrinogen disorders. These can be manifested by bleeding complications, where changes in the MCF parameter are the most useful tool for assessing the effectiveness of fibrinogen replacement therapy. ROTEM-guided bleeding management algorithms effectively reduce the number of transfusions, healthcare costs, and complications, leading to the improvement of patient safety and overall health.

Perioperative Mass Transfusion Affects In-Hospital but Not Follow-Up Survival in Patients with Acute Type A Aortic Dissection

Background and Objectives: The aim of this study was to analyze the influence of mass transfusion on the postoperative outcome and survival in patients presenting with acute Type A aortic dissection. Materials and Methods: Between 2002 and 2020, a total of 505 patients were surgically treated for an acute Type A aortic dissection. Mass transfusion was defined as the peri- and postoperative replacement by transfusion of 10 units. Patient characteristics and outcomes were analyzed and compared between patients with and without mass transfusion. Results: Mass transfusion occurred in 105 patients (20%). The incidences of symptomatic coronary malperfusion (p = 0.017) and tamponade (p = 0.043) were higher in patients with mass transfusion. There was no statistically significant difference in the distal extension of the aortic dissection between the two groups. A valved conduit was significantly more common in patients with mass transfusion (p = 0.007), while the distal aortic repair was similar between the two groups. Cardiopulmonary bypass time (p < 0.001), cross clamp time (p < 0.001) and in-hospital mortality were significantly higher in patients with mass transfusion (p < 0.001), but the survival after discharge (landmark-analysis) showed equal survival between patients with and without mass transfusion (log rank: p = 0.4). Mass transfusion was predictive of in-hospital mortality (OR: 3.308, p < 0.001) but not for survival after discharge (OR: 1.205, p = 0.661). Conclusions: Mass transfusion is necessary in many patients with acute Type A aortic dissection. These patients present sicker and require longer surgery. However, mass transfusion does not influence survival after discharge.

Impact of Baseline Anemia in Patients Undergoing Transcatheter Aortic Valve Replacement: A Prognostic Systematic Review and Meta-Analysis

Transcatheter aortic valve replacement (TAVR) is currently the treatment of choice for patients aged ≥75 years with severe aortic stenosis. Preoperative anemia is present in a large proportion of patients and may increase the risk of post-procedural complications. The purpose of this prognostic systematic review was to analyze the impact of baseline anemia on short- and mid-term outcomes following TAVR. A computerized search was performed on PubMed and Web of Science databases for studies published between January 2013 and December 2022. Primary outcomes were 30-day need for transfusion, acute renal failure, 30-day and mid-term mortality, and readmission during the first year post-TAVR. Data were analyzed via random effects model using inverse variance method with 95% confidence intervals. Eleven observational studies met our eligibility criteria and included a total of 12,588 patients. The prevalence of baseline anemia ranged between 39% and 72%, with no relevant sex differences. Patients with preprocedural anemia received more blood transfusions [OR: 2.95 (2.13-4.09)]), and exhibited increased rates of acute kidney injury [OR:1.74 (1.45-2.10)], short-term mortality [OR: 1.47 (1.07-2.01], and mid-term [OR: 1.89 (1.58-2.25)] mortality following TAVR compared with those without anemia. Baseline anemia determined an increased risk for blood transfusion, acute kidney injury, and short/mid-term mortality among TAVR recipients.

Combined Platelet and Red Blood Cell Recovery during On-pump Cardiac Surgery Using same™ by i-SEP Autotransfusion Device: A First-in-human Noncomparative Study (i-TRANSEP Study)

BACKGROUND

Centrifugation-based autotransfusion devices only salvage red blood cells while platelets are removed. The same™ device (Smart Autotransfusion for ME; i-SEP, France) is an innovative filtration-based autotransfusion device able to salvage both red blood cells and platelets. The authors tested the hypothesis that this new device could allow a red blood cell recovery exceeding 80% with a posttreatment hematocrit exceeding 40%, and would remove more than 90% of heparin and 75% of free hemoglobin.

METHODS

Adults undergoing on-pump elective cardiac surgery were included in a noncomparative multicenter trial. The device was used intraoperatively to treat shed and residual cardiopulmonary bypass blood. The primary outcome was a composite of cell recovery performance, assessed in the device by red blood cell recovery and posttreatment hematocrit, and of biologic safety assessed in the device by the washout of heparin and free hemoglobin expressed as removal ratios. Secondary outcomes included platelet recovery and function and adverse events (clinical and device-related adverse events) up to 30 days after surgery.

RESULTS

The study included 50 patients, of whom 18 (35%) underwent isolated coronary artery bypass graft, 26 (52%) valve surgery, and 6 (12%) aortic root surgery. The median red blood cell recovery per cycle was 86.1% (25th percentile to 75th percentile interquartile range, 80.8 to 91.6) with posttreatment hematocrit of 41.8% (39.7 to 44.2). Removal ratios for heparin and free hemoglobin were 98.9% (98.2 to 99.7) and 94.6% (92.7 to 96.6), respectively. No adverse device effect was reported. Median platelet recovery was 52.4% (44.2 to 60.1), with a posttreatment concentration of 116 (93 to 146) · 109/l. Platelet activation state and function, evaluated by flow cytometry, were found to be unaltered by the device.

CONCLUSIONS

In this first-in-human study, the same™ device was able to simultaneously recover and wash both platelets and red blood cells. Compared with preclinical evaluations, the device achieved a higher platelet recovery of 52% with minimal platelet activation while maintaining platelet ability to be activated in vitro.

EDITOR’S PERSPECTIVE

Patient blood management programmes: keeping the ball rolling

Patient blood management programmes have been endorsed by the World Health Organization and multiple medical societies. It seems important to review the progress and results of patient blood management programmes so necessary modifications or new initiatives can be added to achieve their major goals. In this issue of the British Journal of Anaesthesia, Meybohm and colleagues show that a nationwide patient blood management programme had an impact and was potentially cost-effective in centres that previously utilised large amounts of allogeneic blood transfusions. Before implementing a programme, each institution might need to identify the area(s) of deficiency with respect to established patient blood management methods, which will warrant specific focus in subsequent clinical practice reviews.

Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo

BACKGROUND

Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation.

METHODS

Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis.

RESULTS

Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline.

CONCLUSIONS

Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.

PECAM-1/Thrombus Ratio Correlates with Blood Loss during Off-Pump Coronary Artery Bypass Grafting (OPCAB) Surgery: A Preliminary Study

Platelet endothelial cell adhesion molecule 1 (PECAM-1) is considered an antiplatelet molecule. Previously, we introduced a new parameter called the PECAM-1/thrombus ratio, which indicates the proportion of PECAM-1 in the thrombus and provides a precise description of human platelet activity (in vitro). The aim of this study was to determine whether the PECAM-1/thrombus ratio could serve as a predictive factor for bleeding events during off-pump coronary artery bypass grafting (OPCAB). To achieve this, we collected blood samples from 20 patients scheduled to undergo OPCAB surgery. We assessed the PECAM-1/thrombus ratio by evaluating thrombus formation on collagen fibers under flow conditions. Subsequently, we compared the ability of the PECAM-1/thrombus ratio in predicting bleeding risk with other methods that evaluate hemostasis activity. These methods included assessing platelet P-selectin secretion, platelet exposure of phosphatidylserine, plasma coagulation and fibrinolysis system activity, and thrombus formation using the T-TAS assay. Our findings revealed a positive correlation between the PECAM-1/thrombus ratio and the amount of blood component units transfused (BCUT) during the OPCAB surgery. Furthermore, BCUT did not show any significant correlation with other measured hemostasis parameters. This preliminary study suggests that the PECAM-1/thrombus ratio might be a good predictor of bleeding risk during the OPCAB procedure.

Safety and efficacy of total thoracoscopic surgery for patients with tricuspid regurgitation and reduced right ventricular function after left heart valves replacement: a retrospective comparative study

BACKGROUND

Tricuspid valve surgery is the standard treatment for tricuspid valve disease refractory to pharmacologic therapy. However, patients with tricuspid regurgitation after previous left heart valves replacement with reduced right ventricular (RV) function are at greater risk of surgery. We compared the clinical outcomes of tricuspid valve replacement in this subgroup of patients through mini-thoracotomy and conventional full-sternotomy approach.

METHODS

We identified 44 patients at our institution with tricuspid regurgitation and reduced right ventricular function after left heart valves replacement who underwent either total thoracoscopic tricuspid valve replacement (T-TVR) or conventional tricuspid valve replacement (C-TVR) from December 2014 and May 2021. Patient clinical characteristics, hospital course, and postoperative changes in RV function were retrospectively reviewed and analyzed.

RESULTS

Baseline characteristics between T-TVR (n = 25) and C-TVR (n = 19) were comparable including a high incidence of liver dysfunction and renal insufficiency. There were no statistically differences between the two groups in terms of hospital mortality (8.0% vs. 21.1%, P = .211). Patients in the T-TVR group had less total drainage volume (201.60 ± 77.05 ml vs. 614.74 ± 182.31 ml, p < .001), required fewer postoperative blood product transfusions, and had a lower total length of hospital stay (15(15-16) vs. 16(14-17) days, P = .019) compared to the C-TVR group. T-TVR was associated with better and faster recovery of tricuspid annular plane systolic excursion (TAPSE) and right ventricle fractional area change (RVFAC) (adjusted β = 0.154, 95% CI: 0.037 to 0.271, p = .010 and adjusted β = 0.003, 95% CI: 0.000 to 0.005, p = .024; respectively) within the first 3 months postoperatively compared with C-TVR.

CONCLUSIONS

T-TVR represents a viable alternative to current surgical strategies as a potentially sicker cohort demonstrated similar hospital mortality compared to conventional surgery, with reduced length of hospital stay, fewer blood transfusions, and more favorable in promoting RV functional recovery in the early period. Future prospective, randomized-controlled trials with longer follow-up durations are needed to validate these findings.

A Potential Indicator for Assessing Patient Blood Management Standard Implementation

(1) Background: Patient blood management (PBM) program as a multidisciplinary practice and a standard of care for the anemic surgical patient has an increasingly important role in reducing transfusions and optimizing both clinical outcomes and costs. Documented success of PBM implementation is not sufficient for implementation of recommendations and correct use at hospital level. The primary objective of our study was to define a composite patient blood management process safety index-Safety Index in PBM (SIPBM)-that measures the impact of screening and treating anemic patients on the efficiency and effectiveness of the patient care process undergoing elective surgery. (2) Methods: We conducted a retrospective comparative study in a tertiary hospital by collecting data and analyzing the Safety Index in PBM (SIPBM) in patients undergoing major elective surgical procedures. (3) Results: The percentage of patients from the total of 354 patients (178 in 2019 and 176 in 2022) included in the study who benefited from preoperative iron treatment increased in 2022 compared to 2019 from 27.40% to 36.71%. The median value of the SIPBM was 1.00 in both periods analyzed, although there is a significant difference between the two periods (p < 0.005), in favor of 2022. (4) Conclusions: Measuring the effectiveness of PBM implementation and providing ongoing feedback through the Safety Index in PBM (SIPBM) increases the degree to which opportunities to improve the PBM process are identified. The study represents a first step for future actions and baselines to develop tools to measure the safety and impact of the patient blood management process in the surgical field.

Everyday Cardiac Surgery in Jehovah's Witnesses of Typically Advanced Age: Clinical Outcome and Matched Comparison

BACKGROUND AND OBJECTIVES

Jehovah's Witnesses (JW) reject the transfusion of blood components based on their religious beliefs, even if they are in danger of harm or death. In cardiac surgery, this significantly reduces the margin of safety and leads to ethical conflicts. Informed consent should be carefully documented and the patient's family should be involved. This study aims to compare the postoperative course of JW who underwent major cardiac surgery with a similar population of non-Witnesses (NW).

PATIENTS AND METHODS

Demographic, procedural, and postoperative data of all consecutive JW who underwent cardiac surgery at our institution were obtained from the records. They were compared with a propensity-score-matched group of NW. Anemic JW were treated with erythropoietin and/or iron as needed. Cardiac surgery was performed by experienced surgeons using median sternotomy and cardiopulmonary bypass. Common blood-sparing techniques were routinely used. Periprocedural morbidity and mortality were statistically evaluated for both groups.

RESULTS

A total of 32 JW and 64 NW were part of the matched dataset, showing no demographic or procedural differences. EPO was used preoperatively in 34.4% and postoperatively in 15.6% of JW but not in NW. Preoperative hemoglobin levels were similar (JW, 8.09 ± 0.99 mmol/L; NW, 8.18 ± 1.06; p = 0.683). JW did not receive any transfusions except for one who revoked, while NW transfusion rates were 2.5 ± 3.1 units for red cells (p < 0.001) and 0.3 ± 0.8 for platelets (p = 0.018). Postoperative levels differed significantly for hemoglobin (JW, 6.05 ± 1.00 mmol/L; NW, 6.88 ± 0.87; p < 0.001), and hematocrit (JW, 0.29 ± 0.04; NW, 0.33 ± 0.04; p < 0.001) but not for creatinine. Early mortality was similar (JW, 6.3%; NW, 4.7%; p = 0.745). There were more pacemakers and pneumonias in JW, while all other postoperative conditions were not different.

CONCLUSIONS

Real-world data indicate that Jehovah's Witnesses can safely undergo cardiac surgery provided that patients are preconditioned and treated by experienced surgeons who use blood-saving strategies. Postoperative anemia is observed but does not translate into a worse clinical outcome. This is consistent with other studies. Finally, the results of this study suggest that all patients should benefit from optimal pretreatment and blood-sparing strategies in cardiac surgery, not just Jehovah's Witnesses.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

High level of intraoperative lactate might predict acute kidney injury in aortic arch surgery via minimally invasive approach in patients with type A dissection

Background

A high incidence of acute kidney injury (AKI) has been recorded in total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation in patients with acute type A dissection (ATAAD) via median sternotomy approach with some risk factors. However, the independent risk factors for AKI via a minimally invasive approach have not yet been identified.

Methods

A total of 207 patients with ATAAD were enrolled from January 2018 and November 2019 and were divided into AKI and non-AKI groups. The current surgical strategy was TAR combined with FET via a single upper hemisternotomy approach, a minimally invasive method. An increase in the serum creatinine (Cr) level to ≥2 times the baseline level 48 h post-surgery was defined as AKI. The morbidity of AKI was investigated with a step-by-step backward multivariate analysis of its independent risk factors and a receiver-operating characteristic curve analysis.

Results

Postoperative AKI was observed in 39 (18.8%) patients, and the total hospital mortality was 8.7%. Univariate analysis found that preoperative Cr, weight, circulatory arrest time ≥60 min, intraoperative highest lactate (Lac), and intraoperative transfusion had significant differences between the two groups. However, multivariate step-by-step backward logistic regression analysis identified intraoperative highest Lac and transfusion as independent risk factors for postoperative AKI and intraoperative highest Lac was identified as the most critical independent risk factor estimated by the partial chi-square statistic minus the predicted degrees of freedom with 4.3 mmol/L as the optimal cut-off point for prediction for AKI.

Conclusions

Intraoperative highest Lac and transfusion were independent risk factors for postoperative AKI, which led to high hospital mortality. Moreover, intraoperative highest Lac was the most critical independent risk factor and high level of intraoperative highest Lac (4.3 mmol/L) might predict for postoperative AKI.

Perioperative Red Blood Cell Transfusion Is Associated With Adverse Cardiovascular Outcomes in Heart Valve Surgery

BACKGROUND

We examined the relationship between blood transfusion and long-term adverse events to evaluate the clinical impact of red blood cell (RBC) transfusion on patients undergoing cardiac valve surgery.

METHODS

From the National Health Insurance Service database, individuals undergoing heart valve surgery were verified, including aortic valve (AV), mitral valve (MV), tricuspid valve (TV), and complex valves (more than 2 valve surgeries). The interested outcomes were incidence of death, ischemic stroke, hemorrhagic stroke, and admission for myocardial infarction during follow-up. Associations between perioperative RBC transfusion and long-term cardiovascular events were analyzed with Cox-proportional hazard model.

RESULTS

Perioperative RBC transfusion (±2 days from the day of surgery) was categorized into 0, 1, 2, and >3 units based on the number of packs transfused. From 2003 to 2019, the data of 58,299 individuals were retrieved (51.6% were male and 58% were aged above 60 years). The median follow-up duration was 5.53 years. Of the total cohort, 86.5% received at least 1 transfusion. In multivariable analysis, adverse cardiovascular event risk proportionally increased with transfusion in a dose-dependent manner. The adjusted hazard ratios and 95% confidence intervals of outcomes after the transfusion of 1, 2, and ≥3 units compared to those with no transfusion were as follows: death, 1.53 (1.41-1.66), 1.97 (1.81-2.14), and 3.03 (2.79-3.29); ischemic stroke, 1.27 (1.16-1.39), 1.31 (1.19-1.44), and 1.51 (1.38-1.66); hemorrhagic stroke, 1.38 (1.16-1.66), 1.71 (1.43-2.05), and 2.31 (1.94-2.76); and myocardial infarction 1.35 (1.13-1.62), 1.60 (1.33-1.91), and 1.99 (1.66-2.38), respectively (all P < .01).

CONCLUSIONS

In the analysis of the national cohort, perioperative RBC transfusion during heart valve surgery was associated with adverse cardiovascular outcomes correlated with the volume of RBC transfusion.

In vitro study on the effect of fibrinogen γ-chain peptide-coated ADP-encapsulated liposomes on postcardiopulmonary bypass coagulopathy using patient blood

BACKGROUND

Fibrinogen γ-chain peptide-coated, adenosine 5'-diphosphate (ADP)-encapsulated liposomes (H12-ADP-liposomes) are potent hemostatic adjuvants that promote platelet thrombi formation at bleeding sites. Although we have reported the efficacy of these liposomes in a rabbit model of cardiopulmonary bypass coagulopathy, we are yet to address the possibility of their hypercoagulative potential, especially in human beings.

OBJECTIVES

Considering its future clinical applications, we herein investigated the safety of using H12-ADP-liposomes in vitro using blood samples from patients who had received platelet transfusion after cardiopulmonary bypass surgeries.

METHODS

Ten patients receiving platelet transfusions after cardiopulmonary bypass surgery were enrolled. Blood samples were collected at the following 3 points: at the time of incision, at the end of the cardiopulmonary bypass, and immediately after platelet transfusion. After incubating the samples with H12-ADP-liposomes or phosphate-buffered saline (PBS, as a control), blood coagulation, platelet activation, and platelet-leukocyte aggregate formation were evaluated.

RESULTS

Patients' blood incubated with H12-ADP-liposomes did not differ from that incubated with PBS in coagulation ability, degree of platelet activation, and platelet-leukocyte aggregation at any of the time points.

CONCLUSION

H12-ADP-liposomes did not cause abnormal coagulation, platelet activation, or platelet-leukocyte aggregation in the blood of patients who received platelet transfusion after a cardiopulmonary bypass. These results suggest that H12-ADP-liposomes could likely be safely used in these patients, providing hemostasis at the bleeding sites without causing considerable adverse reactions. Future studies are needed to ensure robust safety in human beings.

Less (Transfusion) Is More-Enhancing Recovery through Implementation of Patient Blood Management in Cardiac Surgery: A Retrospective, Single-Centre Study of 1174 Patients

Introduction: The implementation of Patient Blood Management (PBM) in cardiac surgery has been shown to be effective in reducing blood transfusions and associated complications, as well as improving patient outcomes. Despite the potential benefits of PBM in cardiac surgery, there are several barriers to its successful implementation. Objectives: The main objectives of this study were to ascertain the impact of the national Romanian PBM recommendations on allogeneic blood product transfusion in cardiac surgery and identify predictors of perioperative packed red blood cell transfusion. Methods: As part of the Romanian national pilot programme of PBM, we performed a single-centre, retrospective study in a tertiary centre of cardiovascular surgery, including patients from two time periods, before and after the implementation of the national recommendations. Using coarsened exact matching, from a total of 1174 patients, 157 patients from the before group were matched to 169 patients in the after group. Finally, we built a multivariate regression model from the entire cohort to analyse independent predictors of PRBC transfusion in the perioperative period. Results: Although there was a trend towards a lower proportion of patients requiring PRBC transfusion in the "after" group compared to the "before" group (44.9%vs. 50.3%), it was not statistically significant. There was a significant difference between the "after" group and the "before" group in terms of fresh-frozen plasma (FFP) transfusion rates, with a lower percentage of patients requiring FFP transfusion in the "after" group compared to "before" (14.2%, vs. 22.9%, p = 0.04). This difference was also seen in the total perioperative FFP transfusion (mean transfusion 0.7 units in the "before" group, SD 1.73 vs. 0.38 units in the "after" group, SD 1.05, p = 0.04). In the multivariate regression analysis, age > 64 years (OR 1.652, 95% CI 1.17-2.331, p = 0.004), female sex (OR 2.404, 95% CI 1.655-3.492, p < 0.001), surgery time (OR 1.295, 95% CI 1.126-1.488, p < 0.001), Hb < 13 g/dl (OR 3.611, 95% CI 2.528-5.158, p < 0.001), re-exploration for bleeding (OR 3.988, 95% CI 1.248-12.738, p = 0.020), viscoelastic test use (OR 2.18, 95% CI 1.34-3.544, p < 0.001), FFP transfusion (OR 4.023, 95% CI 2.426-6.671, p < 0.001), and use of a standardized pretransfusion checklist (OR 8.875, 95% CI 5.496-14.332, p < 0.001) remained significantly associated with PRBC transfusion. The use of a preoperative standardized haemostasis questionnaire was independently associated with a decreased risk of perioperative PRBC transfusion (0.565, 95% CI 0.371-0.861, p = 0.008). Conclusions: Implementation of national PBM recommendations led to a reduction in FFP transfusion in a cardiac surgery centre. The use of a preoperative standardized haemostasis questionnaire is an independent predictor of a lower risk for PRBC transfusion in this setting.

Long-term Outcome of Reexploration for Bleeding After Coronary Artery Bypass Grafting

OBJECTIVES

This study aimed to determine the influence of reexploration for bleeding and blood product requirement after coronary artery bypass grafting (CABG) on long-term mortality.

DESIGN

A retrospective cohort study.

SETTING

A single-center institution.

PARTICIPANTS

All patients who underwent CABG between January 1998 and December 2019 were included.

INTERVENTIONS

The parameters were analyzed to assess the association between reexploration for bleeding and long-term mortality.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was all-cause mortality up to the end of follow-up (June 1, 2021). The secondary endpoints were 30-day mortality, duration of admission, blood product transfusion, postoperative use of an intra-aortic balloon pump, deep sternal wound infection, myocardial infarction, and neurologic complications. The Cox proportional hazards model was used to assess the association between reexploration and blood product use and all-cause mortality. Median follow-up was 9.7 years (IQR 5.1-14.6). In total, 576 out of 21,346 (2.7%) patients were reexplored for bleeding. Thirty-day mortality was 6.2% v 1.6% for the reexplored versus not reexplored patients. Reexploration for bleeding was not significantly correlated with long-term mortality (hazard ratio [HR] 1.029; p = 0.068). On the other hand, blood product transfusion (HR = 1.135; p < 0.001), and in particular, packed red blood cell (pRBC) transfusion (HR = 1.139; p < 0.001), was significantly associated with higher long-term mortality. After multivariate Cox regression using ≥5 pRBC transfused as a cut-off point, reexploration for bleeding was not significantly associated with long-term mortality (HR 0.982; p = 0.813). Receiving ≥5 pRBCs was significantly associated with higher long-term mortality (HR 1.249; p < 0.001).

CONCLUSION

Reexploration for bleeding was significantly associated with higher 30-day mortality but not with long-term mortality. Poorer long-term mortality was attributed to patient characteristics and higher use of postoperative blood products.

Efficacy of autologous plateletpheresis in adult aortic surgery: study protocol for a randomised controlled trial

INTRODUCTION

Perioperative coagulopathy is common in patients undergoing aortic surgery, increasing the risk of excessive blood loss and subsequent allogeneic transfusion. Blood conservation has become a vital part of cardiovascular surgery, but measures to protect platelets from destruction by cardiopulmonary bypass (CPB) are still lacking. Autologous platelet concentrate (APC) may have potential benefits for intraoperative blood preservation, but its efficacy has not been studied extensively. This study aims to evaluate the efficacy of APC as a blood conservation technique to reduce blood transfusion in adult aortic surgery.

METHODS AND ANALYSIS

This is a prospective, single-centre, single-blind randomised controlled trial. A total of 344 adult patients undergoing aortic surgery with CPB will be enrolled and randomised to either the APC group or the control group with a 1:1 randomisation ratio. Patients in the APC group will receive autologous plateletpheresis before heparinisation, while those in the control group will not. The primary outcome is the perioperative packed red blood cell (pRBC) transfusion rate. Secondary endpoints include the volume of perioperative pRBC transfusion; drainage volume within 72 hours post-surgery; postoperative coagulation and platelet function; and the incidence of adverse events. Data will be analysed according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

This study was approved by the institutional review board of Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (no. 2022-1806). All procedures included in this study will be performed in adherence to the Helsinki Declaration. The results of the trial will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Register (ChiCTR2200065834).