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Fiameni R, Lucchelli M, Novelli C, Salice V, Orsenigo F, Gomarasca M, MoroSalihovic B, Mondin F, Mistraletti G, Beverina I. Impact of introduction of a goal directed transfusion strategy in a patient blood management program: A single cardiac surgery centre experience. Transfus Med 2024. [PMID: 38945994 DOI: 10.1111/tme.13063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 05/16/2024] [Accepted: 06/18/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The aim of this retrospective and observational study was to analyse the impact of the introduction of a goal directed transfusion (GDT) strategy based on a viscoelastic test (ROTEM®) and specific procoagulant products in a patient blood management (PBM) Program on blood product use and perioperative bleeding in a single cardiac surgery centre. STUDY DESIGN AND METHODS Patient population underwent cardiac surgery from 2011 to 2021 was divided in two groups based on PBM protocol used (G#11-14, years 2011-2014, G#15-21, years 2015-2021) and compared for the following variables: intraoperative and postoperative transfusions of packed red blood cell and any procoagulant products, postoperative drain blood loss volume and rate of re-exploration surgery. The second program was defined after the introduction of a GDT protocol based on viscoelastic tests and specific procoagulant products. RESULTS After the introduction of a GDT protocol, about 80% less amongst patients were transfused with fresh frozen plasma and any procoagulant product (p < 0.001 for both phases). Moreover, similar results were obtained with PRBC transfusions (p < 0.001) and drain blood loss volume (p = 0.006) in the postoperative phase. The main factors affecting the use of any procoagulant and PBRC transfusion in the multivariate logistic regression analysis was Group (2 versus 1, OR 0.207, p < 0.001) and preoperative haemoglobin (OR 0.728, p < 0.001), respectively. DISCUSSION In our experience, a GDT strategy for the diagnosis and treatment of the coagulopathy in patients undergone cardiac surgery led to a significant reduction in bleeding and transfusion.
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Affiliation(s)
- Riccardo Fiameni
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Matteo Lucchelli
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Chiara Novelli
- S.C. Immunoematologia e Centro Trasfusionale, ASST Ovest Milanese, Legnano, Italy
| | - Valentina Salice
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Francesca Orsenigo
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Mattia Gomarasca
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | | | - Federico Mondin
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
| | - Giovanni Mistraletti
- S.C. Rianimazione e Anestesia Legnano, ASST Ovest Milanese, Legnano, Italy
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Italy
| | - Ivo Beverina
- S.C. Immunoematologia e Centro Trasfusionale, ASST Ovest Milanese, Legnano, Italy
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Wu Z, Chen L, Guo W, Wang J, Ni H, Liu J, Jiang W, Shen J, Mao C, Zhou M, Wan M. Oral mitochondrial transplantation using nanomotors to treat ischaemic heart disease. NATURE NANOTECHNOLOGY 2024:10.1038/s41565-024-01681-7. [PMID: 38802669 DOI: 10.1038/s41565-024-01681-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 04/15/2024] [Indexed: 05/29/2024]
Abstract
Mitochondrial transplantation is an important therapeutic strategy for restoring energy supply in patients with ischaemic heart disease (IHD); however, it is limited by the invasiveness of the transplantation method and loss of mitochondrial activity. Here we report successful mitochondrial transplantation by oral administration for IHD therapy. A nitric-oxide-releasing nanomotor is modified on the mitochondria surface to obtain nanomotorized mitochondria with chemotactic targeting ability towards damaged heart tissue due to nanomotor action. The nanomotorized mitochondria are packaged in enteric capsules to protect them from gastric acid erosion. After oral delivery the mitochondria are released in the intestine, where they are quickly absorbed by intestinal cells and secreted into the bloodstream, allowing delivery to the damaged heart tissue. The regulation of disease microenvironment by the nanomotorized mitochondria can not only achieve rapid uptake and high retention of mitochondria by damaged cardiomyocytes but also maintains high activity of the transplanted mitochondria. Furthermore, results from animal models of IHD indicate that the accumulated nanomotorized mitochondria in the damaged heart tissue can regulate cardiac metabolism at the transcriptional level, thus preventing IHD progression. This strategy has the potential to change the therapeutic strategy used to treat IHD.
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Affiliation(s)
- Ziyu Wu
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lin Chen
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Wenyan Guo
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Jun Wang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Haiya Ni
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianing Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Wentao Jiang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Jian Shen
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China
| | - Chun Mao
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China.
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine, Nanjing, China.
| | - Mimi Wan
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, China.
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3
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Balkan B, Ulubay ZÖ, Güneysu E, Dündar AS, Turan EI. Determinants of 30-day mortality in elderly patients admitted to a cardiovascular surgery intensive care unit. ULUS TRAVMA ACIL CER 2024; 30:328-336. [PMID: 38738671 PMCID: PMC11154066 DOI: 10.14744/tjtes.2024.00569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 11/28/2023] [Accepted: 04/19/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND This study aims to identify the factors influencing 30-day morbidity and mortality in patients aged 65 and older undergoing cardiovascular surgery. METHODS Data from 360 patients who underwent cardiac surgery between January 2012 and August 2021 in the Cardiovascular Surgery Intensive Care Unit (CVS ICU) were analyzed. Patients were categorized into two groups: "mortality+" (33 patients) and "mortality-" (327 patients). Factors influencing mortality, including preoperative, intraoperative, and postoperative risk factors, complications, and outcomes, were assessed. RESULTS Significant differences were observed between the two groups in factors affecting mortality, including extubation time, ICU stay duration, blood transfusion, surgical reexploration, aortic clamp duration, glomerular filtration rate (GFR), blood urea nitrogen (BUN), creatinine, hemoglobin A1c (HbA1c) levels, and the lowest systolic blood pressure during the first 24 hours in the ICU (p<0.05). The "mortality+" group had longer extubation times and ICU stays, required more blood transfusions, and had higher BUN-creatinine ratios, but lower systolic blood pressures, GFR, and HbA1c levels. Mortality was also higher in patients needing noradrenaline infusions and those who underwent reoperation for bleeding (p<0.05). CONCLUSION By optimizing preoperative renal function, minimizing extubation time, shortening ICU stays, and carefully managing blood transfusions, surgical reexplorations, aortic clamp duration, and HbA1c levels, we believe that the mortality rate can be reduced in elderly patients. Key strategies include shortening aortic clamp times, reducing perioperative blood transfusions, and ensuring effective bleeding control.
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Affiliation(s)
- Bedih Balkan
- Department of Anesthesiology and Reanimation, Intensive Care, Health Sciences University Kanuni Sultan Süleyman Training and Research Hospital, İstanbul-Türkiye
| | - Zahide Özlem Ulubay
- Department of Anesthesiology and Reanimation, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research İstanbul-Türkiye
| | - Elif Güneysu
- Department of Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul-Türkiye
| | - Ahmet Said Dündar
- Department of Internal Medicine, Health Sciences University Kanuni Sultan Süleyman Training and Research Hospital, İstanbul-Türkiye
| | - Engin Ihsan Turan
- Department of Anesthesiology and Reanimation Health Sciences University Kanuni Sultan Süleyman Training and Research Hospital, İstanbul-Türkiye
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Lee H, Kim J, Lee JH, Yoo JS. Minimally Invasive Approach versus Sternotomy for Cardiac Surgery in Jehovah's Witness Patients. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00295-7. [PMID: 38955617 DOI: 10.1053/j.jvca.2024.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. SETTING The study was conducted at a specialized cardiovascular intervention and surgery institute. PARTICIPANTS The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). CONCLUSIONS MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jihoon Kim
- Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jong Hyun Lee
- Department of Anesthesiology and Pain Medicine, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Bucheon Sejong Hospital, Bucheon, Gyeonggi-do, Republic of Korea.
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Arafat AA, AlBarrak M, Kiddo M, Alotaibi K, Ismail HH, Adam AI, Aboughanima MA, Albabtain MA, Tantawy TM, Pragliola C. Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock after valve replacement. Perfusion 2024; 39:564-570. [PMID: 36645201 DOI: 10.1177/02676591231152723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves. METHODS This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups. RESULTS There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years. CONCLUSIONS Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.
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Affiliation(s)
- Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Mohammed AlBarrak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Musab Kiddo
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Khaled Alotaibi
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Huda H Ismail
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Adam I Adam
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | | | - Monirah A Albabtain
- Cardiology Clinical Pharmacy Department, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Tarek M Tantawy
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
- Intensive Care Department, Cairo University, Cairo, Egypt
| | - Claudio Pragliola
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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Miazza J, Vasiloi I, Koechlin L, Gahl B, Reuthebuch O, Eckstein FS, Santer D. Combined Band and Plate Fixation as a New Individual Option for Patients at Risk of Sternal Complications after Cardiac Surgery: A Single-Center Experience. Biomedicines 2023; 11:1946. [PMID: 37509585 PMCID: PMC10377508 DOI: 10.3390/biomedicines11071946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.
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Affiliation(s)
- Jules Miazza
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Ion Vasiloi
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Luca Koechlin
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| | - Oliver Reuthebuch
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - Friedrich S Eckstein
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
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Pearl RG, Cole SP. Development of the Modern Cardiothoracic Intensive Care Unit and Current Management. Crit Care Clin 2023; 39:559-576. [PMID: 37230556 DOI: 10.1016/j.ccc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The modern cardiothoracic intensive care unit (CTICU) developed as a result of advances in critical care, cardiology, and cardiac surgery. Patients undergoing cardiac surgery today are sicker, frailer, and have more complex cardiac and noncardiac morbidities. CTICU providers need to understand postoperative implications of different surgical procedures, complications that can occur in CTICU patients, resuscitation protocols for cardiac arrest, and diagnostic and therapeutic interventions such as transesophageal echocardiography and mechanical circulatory support. Optimum CTICU care requires a multidisciplinary team with collaboration between cardiac surgeons and critical care physicians with training and experience in the care of CTICU patients.
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Affiliation(s)
- Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589.
| | - Sheela Pai Cole
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589
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8
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Gopal K, Vytla P, Krishna N, Ravindran G, Micka R, Jose R, Varma PK. Early and midterm outcomes after off pump coronary artery bypass surgery. Indian J Thorac Cardiovasc Surg 2023; 39:332-339. [PMID: 37346442 PMCID: PMC10279599 DOI: 10.1007/s12055-023-01475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023] Open
Abstract
Purpose There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality. Methods This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed. Results Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24 h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62 years, postoperative renal failure, IABP usage, ventilation time > 24 h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27 days and 6-year survival was 88.7%. Conclusion OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.
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Affiliation(s)
- Kirun Gopal
- Department of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Ponnekara PO, Kochi, Kerala PIN 682041 India
| | - Prashanth Vytla
- Department of Cardiovascular & Thoracic Surgery, Apollo Hospitals, Jubilee Hills, Rd No 72, Film Nagar, Hyderabad, Telangana 500033 India
| | - Neethu Krishna
- Department of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Ponnekara PO, Kochi, Kerala PIN 682041 India
| | - Greeshma Ravindran
- Department of Biostatistics, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Rohik Micka
- Department of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Ponnekara PO, Kochi, Kerala PIN 682041 India
| | - Rajesh Jose
- Department of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Ponnekara PO, Kochi, Kerala PIN 682041 India
| | - Praveen Kerala Varma
- Department of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Ponnekara PO, Kochi, Kerala PIN 682041 India
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9
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Flynn BC, Steiner ME, Mazzeffi M. Off-label Use of Recombinant Activated Factor VII for Cardiac Surgical Bleeding. Anesthesiology 2023:138187. [PMID: 37155359 DOI: 10.1097/aln.0000000000004569] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Recombinant activated factor VII has been widely used in an off-label manner for cardiac surgical bleeding. Recent reports have administered recombinant activated factor VII earlier in the course of bleeding and at lower doses than initially reported. This review will discuss the history, mechanism, current recommendations for use, and recent data on the use of recombinant activated factor VII in cardiac surgical bleeding.
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Affiliation(s)
- Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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10
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Spadaccio C, Rose D, Nenna A, Taylor R, Bittar MN. Early Re-Exploration versus Conservative Management for Postoperative Bleeding in Stable Patients after Coronary Artery Bypass Grafting: A Propensity Matched Study. J Clin Med 2023; 12:jcm12093327. [PMID: 37176767 PMCID: PMC10179715 DOI: 10.3390/jcm12093327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Postoperative bleeding requiring re-exploration in cardiac surgery has been associated with complications impacting short-term outcomes and perioperative survival. Many aspects of decision-making for re-exploration still remain controversial, especially in hemodynamically stable patients with significant but not acutely cumulating chest drain output. We investigated the impact of re-exploratory surgery on short-term outcomes in a "borderline population" of CABG patients who experienced significant non-acute bleeding, but that were not in critically hemodynamic unstable conditions. METHODS A prospectively collected database of 8287 patients undergoing primary isolated elective CABG was retrospectively interrogated. A population of hemodynamically stable patients experiencing significant non-acute or rapidly cumulating bleeding (>1000 mL of blood loss in 12 h, <200 mL per hour in the first 5 h) with normal platelet and coagulation tests was identified (N = 1642). Patients belonging to this group were re-explored (N = 252) or treated conservatively (N = 1390) based on the decision of the consultant surgeon. Clinical outcomes according to the decision-making strategy were compared using a propensity score matching (PSM) approach. RESULTS After PSM, reoperated patients exhibited significantly higher overall blood product consumption (88.4% vs. 52.6% for red packed cells, p = 0.001). The reoperated group experienced higher rates of respiratory complications (odds ratio 5.8 [4.29-7.86] with p = 0.001 for prolonged ventilation), prolonged stay in intensive care unit (coefficient 1.66 [0.64-2.67] with p = 0.001) and overall length of stay in hospital (coefficient 2.16 [0.42-3.91] with p = 0.015) when compared to conservative management. Reoperated patients had significantly increased risk of multiorgan failure (odds ratio 4.59 [1.37-15.42] with p = 0.014) and a trend towards increased perioperative mortality (odds ratio 3.12 [1.08-8.99] with p = 0.035). CONCLUSIONS Conservative management in hemodynamically stable patients experiencing significant but non-critical or emergency bleeding might be a safe and viable option and might be advantageous in terms of reduction of postoperative morbidities and hospital stay.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - David Rose
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - Antonio Nenna
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rebecca Taylor
- Research and Development, Blackpool Teaching Hospitals, Blackpool FY3 8NR, UK
| | - Mohamad Nidal Bittar
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
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11
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Aplicación de un programa de ahorro de sangre en cirugía cardiaca: análisis y resultados. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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12
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Drosos V, Durak K, Autschbach R, Spillner J, Nubbemeyer K, Zayat R, Kalverkamp S. Video-Assisted Thoracoscopic Surgery Management of Subacute Retained Blood Syndrome after Cardiac Surgery. Ann Thorac Cardiovasc Surg 2022; 28:146-153. [PMID: 34690218 PMCID: PMC9081459 DOI: 10.5761/atcs.oa.21-00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Blood loss along with inadequate evacuation after cardiac surgery leads to retained blood syndrome (RBS) in the pleural and/or pericardial cavity. Re-sternotomy is often needed for clot evacuation. Video-assisted thoracoscopic surgery (VATS) evacuation is a less-invasive procedure. However, sufficient evidence on safety and outcomes is lacking. METHODS Thirty patients who developed hemothorax and/or hemopericardium after cardiac surgery and underwent VATS evacuation between April 2015 and September 2020 were included in this retrospective single-center analysis. RESULTS The median patient age was 70 (interquartile range: IQR 62-75) years, body mass index (BMI) was 24.7 (IQR 22.8-29) kg/m2, time between initial cardiac surgery and VATS was 17 (IQR 11-21) days, 30% of the patients were female, 60% resided in the ICU, and 17% were nicotine users. Coronary artery bypass graft was the most frequent initial cardiac procedure. Median operation time was 120 (IQR 90-143) min, 23% of the patients needed an additional VATS, and the median length of hospital stay after VATS was 8 (IQR 5-14) days. All patients survived VATS, and we experienced no mortality related to the VATS procedure. CONCLUSION In our study, VATS for evacuation of RBS after cardiac surgery was a feasible, safe, and efficient alternative approach to re-sternotomy in selected patients.
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Affiliation(s)
- Vasileios Drosos
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Koray Durak
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Jan Spillner
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Katharina Nubbemeyer
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
| | - Sebastian Kalverkamp
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany
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13
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Biomaterials as Haemostatic Agents in Cardiovascular Surgery: Review of Current Situation and Future Trends. Polymers (Basel) 2022; 14:polym14061189. [PMID: 35335519 PMCID: PMC8955858 DOI: 10.3390/polym14061189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 02/04/2023] Open
Abstract
Intraoperative haemostasis is of paramount importance in the practice of cardiovascular surgery. Over the past 70 years, topical haemostatic methods have advanced significantly and today we deal with various haemostatic agents with different properties and different mechanisms of action. The particularity of coagulation mechanisms after extracorporeal circulation, has encouraged the introduction of new types of topic agents to achieve haemostasis, where conventional methods prove their limits. These products have an important role in cardiac, as well as in vascular, surgery, mainly in major vascular procedures, like aortic dissections and aortic aneurysms. This article presents those agents used for topical application and the mechanism of haemostasis and offers general recommendations for their use in the operating room.
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14
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Mistry N, Shehata N, Carmona P, Bolliger D, Hu R, Carrier FM, Alphonsus CS, Tseng EE, Royse AG, Royse C, Filipescu D, Mehta C, Saha T, Villar JC, Gregory AJ, Wijeysundera DN, Thorpe KE, Jüni P, Hare GMT, Ko DT, Verma S, Mazer CD. Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label, randomized, blinded outcome evaluation trial. Diabetes Obes Metab 2022; 24:421-431. [PMID: 34747087 DOI: 10.1111/dom.14591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 12/21/2022]
Abstract
AIM To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. MATERIALS AND METHODS The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. RESULTS Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679; liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93-1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68-1.59] vs. no diabetes OR 1.02 [0.85-1.22]; Pinteraction = .92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21-0.36]; no diabetes OR [95% CI] 0.40 [0.35-0.47]; Pinteraction = .04). CONCLUSIONS The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.
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Affiliation(s)
- Nikhil Mistry
- Department of Anesthesia, St. Michael's Hospital, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nadine Shehata
- Division of Hematology, Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Paula Carmona
- Department of Anesthesia and Critical Care, Hospital Universitari and Politecnic La Fe, Valencia, Spain
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Raymond Hu
- Department of Anesthesia, Austin Hospital, Melbourne, Victoria, Australia
| | - François M Carrier
- Department of Anesthesiology & Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montreal, Québec, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du CHUM, Montreal, Québec, Canada
| | - Christella S Alphonsus
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Elaine E Tseng
- Division of Adult Cardiothoracic Surgery, Department of Surgery, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California, USA
| | - Alistair G Royse
- Department of Surgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Colin Royse
- Department of Surgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care Medicine, Emergency Institute for Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Chirag Mehta
- Department of Cardiac Anaesthesia, Epic Hospital, Ahmedabad, India
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Juan C Villar
- Fundación Cardioinfantil-Instituto de Cardiología, Bogota, Colombia
- Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | - Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Institute of Health Policy, Management and Evaluation University of Toronto, ICES, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Department of Surgery, Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Institute of Medical Sciences, Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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15
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6555495. [DOI: 10.1093/ejcts/ezac208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
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16
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Senage T, Gerrard C, Moorjani N, Jenkins DP, Ali JM. Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting. J Thorac Dis 2021; 13:5670-5682. [PMID: 34795917 PMCID: PMC8575859 DOI: 10.21037/jtd-21-1241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
Background Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG). Methods A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival. Results Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500–1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival. Conclusions Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.
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Affiliation(s)
- Thomas Senage
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK.,SPHERE (MethodS in Patient-Centred Outcomes and Health Research), University of Nantes, Nantes, France
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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17
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Fazlinović S, Wallinder A, Dellborg M, Furenäs E, Eriksson P, Synnergren M, Lidén H. Outcome and survival after open heart surgery for adults with congenital heart disease - a single center experience. SCAND CARDIOVASC J 2021; 55:345-353. [PMID: 34672849 DOI: 10.1080/14017431.2021.1983639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction. Congenital heart disease (CHD) is the most common type of birth defect today. The adult congenital heart disease (ACHD) population is constantly growing and becoming older and more patients require cardiac surgery. The objective of this study was to review the surgical outcome of the open heart procedures performed on ACHD patients in the last 10 years at Sahlgrenska University Hospital (SUH) through a retrospective descriptive cohort study. Methods. A retrospective data collection was performed for 421 patients who underwent a total of 439 surgical procedures between 2009 and 2018 at the Cardiothoracic department in SUH. The primary outcomes were early (<30 days) and late survival. Secondary outcomes were postoperative complications and independent risk factors for postoperative complications. Results. 30-day mortality was 1.9%. Long-term survival after 3, 5 and 10 years were 96% ± 1, 94.3% ± 1.3 and 92.4% ± 1.8. 82 major complications occurred after 46 procedures (11.6%). The most common major complication was re-exploration due to hemorrhage. Risk factors for major complications were acute surgery and prolonged extracorporeal circulation time. 173 minor complications occurred after 90 procedures (22.5%). The most common minor complication was prolonged intensive care unit stay (>48 h). Conclusion. This study presents satisfactory early and midterm survival. The survival and frequency of major postoperative complications are well in line with what other studies have presented. Patients undergoing resternotomies had no increased risk for mortality or postoperative complications.
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Affiliation(s)
- Sanin Fazlinović
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,ACHD-unit, Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Furenäs
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,ACHD-unit, Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Eriksson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,ACHD-unit, Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Synnergren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Lidén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
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18
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Elassal AA, Al-Ebrahim KE, Debis RS, Ragab ES, Faden MS, Fatani MA, Allam AR, Abdulla AH, Bukhary AM, Noaman NA, Eldib OS. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg 2021; 16:166. [PMID: 34099003 PMCID: PMC8183590 DOI: 10.1186/s13019-021-01545-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
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Affiliation(s)
- Ahmed Abdelrahman Elassal
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | | | - Ragab Shehata Debis
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ehab Sobhy Ragab
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | | | | | - Amr Ragab Allam
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Department of Cardiac Surgery, Naser Institute of Research and Treatment, Cairo, Egypt
| | - Ahmed Hasan Abdulla
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Alahrar Hospital, Zagazig, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Saber Eldib
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
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19
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You P, Zhou X, He P, Zhang J, Mao T, Li X, Wang W, Wen R, Ma R, Wang S, Zhang Y, Xiao Y. A nomogram prediction model for sternal incision problems. Int Wound J 2021; 19:253-261. [PMID: 34036716 PMCID: PMC8762560 DOI: 10.1111/iwj.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/13/2021] [Indexed: 12/21/2022] Open
Abstract
Presently, the incidence and mortality rates of sternal incision problems (SIPs) after thoracotomy remain high, and no effective preventive measures are available. The data on 23 182 patients at Xinqiao Hospital, Army Medical University treated with median sternotomy from 1 August 2009 to 31 July 2019 were retrospectively reviewed. A prediction model of SIPs after median thoracotomy was established using R software and then validated using the bootstrap method. Next, the validity and accuracy of the model were tested and evaluated. In total, 15 426 cases met the requirements of the present study, among which 309 cases were diagnosed with SIPs, with an incidence rate of 2%. The body mass index (BMI), intensive care unit (ICU) time, diabetes mellitus, and revision for bleeding were identified as independent risk factors for postoperative SIPs. The nomogram model achieved good discrimination (73.9%) and accuracy (70.2%) in predicting the risk of SIPs after median thoracotomy. Receiver operating characteristic curve analysis showed that the area under curve of the model was 0.705 (95% confidence interval [CI]: 0.746-0.803); the Hosmer-Lemeshow test showed that χ2 = 6.987 and P = 0.538, and the fitting degree of the calibration curve was good. Additionally, the clinical decision curve showed that the net benefit of the model was greater than 0, and the clinical application value was high. The nomogram based on BMI, ICU time, diabetes mellitus, and revision for bleeding can predict the individualised risk of SIPs after median sternotomy, showing good discrimination and accuracy, and has high clinical application value. It also provides significant guidance for screening high-risk populations and developing intervention strategies.
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Affiliation(s)
- Pan You
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xin Zhou
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Ping He
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Jian Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Tongchun Mao
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Xiang Li
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Wei Wang
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Renguo Wen
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Ruiyan Ma
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Shaoliang Wang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Yiming Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
| | - Yingbin Xiao
- Department of Cardiovascular Surgery, Xinqiao Hospital, Army Medical University, Chongqing, People's Republic of China
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20
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Luan T, Zhuang Y, Nie W, Yang S, Wu Y, Wang R, Dai Y, Zhang H. The death risk factors of patients undergoing re-exploration for bleeding or tamponade after isolated off-pump coronary artery bypass grafting: a case-control study. BMC Cardiovasc Disord 2021; 21:204. [PMID: 33888070 PMCID: PMC8063367 DOI: 10.1186/s12872-021-02017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background The purpose of the study is to identify off-pump patients who are at higher risk of mortality after re-exploration for bleeding or tamponade. Methods We analyzed the data of 3256 consecutive patients undergoing isolated off-pump coronary artery bypass grafting (OPCABG) in our heart center from 2013 through 2020. Fifty-eight patients underwent re-exploration after OPCABG. The 58 patients were divided into death group and survival group according to their discharge status. Propensity score matching (PSM) was performed to analysis the risk factors of death. 15 pairs of cases of two groups were matched well. Results The mortality rate of patients underwent re-exploration after OPCABG for bleeding or tamponade was 27.59% (16/58). In the raw data, we found the patients in death group had higher body mass index (BMI) (P = 0.030), higher cardiac troponin T (cTnT) (P = 0.028) and higher incidence of heart failure before OPCABG (P = 0.003). After PSM, the levels of lactic acid before and after re-exploration (P = 0.028 and P < 0.001) were higher in death group. And the levels of creatinine (P = 0.002) and cTnT (P = 0.017) were higher in the death group after re-exploration. The death group had longer reoperation time (P = 0.010). In addition, the perioperative utilization rate of intra-aortic ballon pump (IABP) (P = 0.027), continuous renal replacement therapy (CRRT) (P < 0.001) and platelet transfusion (P = 0.017) were higher than survival group. Conclusions The mortality rate of patients undergoing re-exploration for bleeding or tamponade after isolated OPCABG is high. More attention should be paid to patients with above risk factors and appropriate measures should be taken in time.
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Affiliation(s)
- Tongxiao Luan
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China.,Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China
| | - Yingzhu Zhuang
- Qingdao Fuwai Cardiovascular Hospital, 201 Nanjing Road, Qingdao, 266034, Shandong Province, China
| | - Weihong Nie
- Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China
| | - Sumin Yang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yuhui Wu
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Rongmei Wang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yunyan Dai
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Hong Zhang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China. .,Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China.
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21
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Tran Z, Williamson C, Hadaya J, Verma A, Sanaiha Y, Chervu N, Gandjian M, Benharash P. Trends and Outcomes of Surgical Re-exploration Following Cardiac Operations in the United States. Ann Thorac Surg 2021; 113:783-792. [PMID: 33878310 DOI: 10.1016/j.athoracsur.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/03/2021] [Accepted: 04/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Surgical re-exploration following cardiac surgery has been associated with increased in-hospital complications and mortality in limited series. The present study examined trends in reoperation and its impact on clinical outcomes and resource use in a nationally-representative cohort. We sought to determine patient and hospital factors associated with re-exploration and reoperative mortality, defined as failure-to-rescue-surgical (FTR-S). METHODS Adult hospitalizations entailing cardiac operations (coronary artery bypass and/or valve) were identified using the 2005-2018 National Inpatient Sample. Procedures were tabulated using International Classification of Diseases codes. Hospitals were ranked into tertiles according to risk-adjusted mortality, with the lowest stratified as high-performing. Multivariable regression models examined factors associated with re-exploration as well as clinical outcomes including FTR-S and resource utilization. RESULTS Of an estimated 3,490,245 hospitalizations, 78,003 (2.23%) required re-exploration with decreasing incidence over time. Valvular procedures, preoperative intra-aortic balloon pump and liver disease were associated with greater likelihood of re-exploration. Reoperation was associated with increased odds of mortality (adjusted odds ratio (AOR): 3.86, 95%CI: 3.61-4.12), perioperative complications and resource utilization. Increasing time from index operation to re-exploration was associated with higher odds of mortality (AOR:1.10/day, 95%CI: 1.07-1.12). High-performing hospitals were associated with lower odds of re-exploration (AOR: 0.88, 95%CI: 0.82-0.95) and FTR-S (AOR: 0.29, 95%CI: 0.23-0.35). CONCLUSIONS Surgical re-exploration following cardiac surgery has declined over time. High performing hospitals demonstrated lower rates of re-exploration and subsequent failure-to-rescue. Although unable to identify specific practices, our study highlights the presence of significant variation in takeback rates and further study of underlying factors is warranted.
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Affiliation(s)
- Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles.
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Rodino AM, Henderson JB, Dobbins KF, Rubin DT, Hollis IB. Impact of Thrombocytopenia on Postoperative Bleeding Incidence in Patients Receiving Aspirin Following Coronary Artery Bypass Grafting. J Pharm Pract 2020; 35:223-228. [PMID: 33084455 DOI: 10.1177/0897190020966193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early postoperative aspirin following coronary artery bypass graft (CABG) surgery has been shown to maintain bypass graft patency, reduce mortality, and prevent adverse cardiovascular events. Despite this known benefit, aspirin may be delayed due to thrombocytopenia and perceived higher bleeding risk. The purpose of this study was to assess the impact of postoperative platelet count on bleeding in patients receiving aspirin after CABG. METHODS A retrospective analysis included all patients who underwent CABG surgery at our institution from April 2014 to June 2018 and received aspirin within 24 hours. The primary outcome was International Society on Thrombosis and Hemostasis (ISTH) major bleeding within 7 days (or up to discharge) following CABG surgery compared between patients with and without postoperative thrombocytopenia. RESULTS This study included 280 patients. Major bleeding occurred in 24.6% of the population, with no difference when stratified by the presence or absence of postoperative thrombocytopenia (27.3% versus 23.8%, p = 0.571). There was no significant difference in hemoglobin fall (13.6% versus 14%, p = 0.948), transfusion requirement (6.1% versus 4.2%, p = 0.531), or critical site bleeding (12.1% versus 7.9%, p = 0.298). CONCLUSION In this single-center analysis of patients who received aspirin within 24 hours of CABG, postoperative thrombocytopenia was not associated with an increase in bleeding.
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Affiliation(s)
- Anne M Rodino
- Department of Pharmacy, 24560Northwestern Memorial Hospital, Chicago, IL, USA
| | - James B Henderson
- Department of Pharmacy, 3065Duke University Hospital, Durham, NC, USA
| | - Kelsey F Dobbins
- Department of Pharmacy, 537791WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Deanna T Rubin
- 15521UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
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Patel K, Adalti S, Runwal S, Singh R, Ananthanarayanan C, Doshi C, Pandya H. Re‐exploration after off‐pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing. J Card Surg 2020; 35:3062-3069. [DOI: 10.1111/jocs.14986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Kartik Patel
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Sudhir Adalti
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Shreyas Runwal
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Rahul Singh
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | | | - Chirag Doshi
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Himani Pandya
- Department of Research U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
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24
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Ali JM, Gerrard C, Clayton J, Moorjani N. Reduced re-exploration and blood product transfusion after the introduction of the Papworth haemostasis checklist†. Eur J Cardiothorac Surg 2020; 55:729-736. [PMID: 30346507 DOI: 10.1093/ejcts/ezy362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/21/2018] [Accepted: 10/17/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery. METHODS The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes. RESULTS Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102 165 ($134 198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit. CONCLUSIONS The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.
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Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - James Clayton
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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25
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Impact of tranexamic acid on bleeding during coronary artery bypass for patients under treatment of low molecular weight heparin. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.713471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Marteinsson SA, Heimisdóttir AA, Axelsson TA, Johannesdottir H, Arnadottir LO, Gardarsdottir HR, Johnsen A, Sigurdsson MI, Helgadottir S, Gudbjartsson T. Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes. SCAND CARDIOVASC J 2020; 54:265-273. [PMID: 32351135 DOI: 10.1080/14017431.2020.1751265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.
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Affiliation(s)
| | | | - Tomas A Axelsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Hera Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Linda O Arnadottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Helga R Gardarsdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Arni Johnsen
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Solveig Helgadottir
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Yan SB, Wang XY, Shang GK, Wang ZH, Deng QM, Song JW, Sai WW, Song M, Zhong M, Zhang W. Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2020; 20:149-160. [PMID: 31523760 DOI: 10.1007/s40256-019-00372-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk. PURPOSE Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design. METHODS The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products. RESULTS A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time. CONCLUSION The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.
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Affiliation(s)
- Sen-Bo Yan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Xiao-Yan Wang
- Department of Pharmacy, Qilu Children's Hospital of Shandong University, Children's Hospital of Jinan, Jinan, Shandong, China
| | - Guo-Kai Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Zhi-Hao Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Key Laboratory of Cardiovascular Proteomics of Shandong Province, Jinan, Shandong, China
| | - Qi-Ming Deng
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Jia-Wen Song
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Wen-Wen Sai
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Ming Song
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Ming Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Wei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China.
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Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:429-450. [PMID: 32082905 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Ali JM, Wallwork K, Moorjani N. Do patients who require re-exploration for bleeding have inferior outcomes following cardiac surgery? Interact Cardiovasc Thorac Surg 2019; 28:613-618. [PMID: 30325417 DOI: 10.1093/icvts/ivy285] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/11/2018] [Accepted: 09/03/2018] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Do patients who require return to theatre (RTT) for bleeding have inferior outcomes following cardiac surgery? Altogether, 598 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In summary, patients who bleed following cardiac surgery and then RTT have increased mortality and experience greater morbidity, including neurological, respiratory and renal complications, which result in increased length of intensive care unit stay and hospital stay. It is not easy to dissect the relative contribution of the blood loss and consequent haemodynamic instability, the RTT and the increased blood product consumption to the inferior outcomes observed, as there is evidence that each is important. However, several studies have demonstrated RTT to be an independent predictor of morbidity and mortality, even when controlling for amount of transfusion. Patients who bleed and RTT beyond 12 h postoperatively appear to have the poorest outcomes, suggesting that the decision to RTT should not be delayed if there are concerns over significant bleeding, to ensure the best patient outcomes.
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Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Kate Wallwork
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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30
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Knapik P, Cieśla D, Saucha W, Knapik M, Zembala MO, Przybyłowski P, Kapelak B, Kuśmierczyk M, Jasiński M, Tobota Z, Maruszewski BJ, Zembala M. Outcome Prediction After Coronary Surgery and Redo Surgery for Bleeding (From the KROK Registry). J Cardiothorac Vasc Anesth 2019; 33:2930-2937. [DOI: 10.1053/j.jvca.2019.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/29/2019] [Accepted: 04/29/2019] [Indexed: 11/11/2022]
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Alaifan T, Alenazy A, Xiang Wang D, Fernando SM, Spence J, Belley-Cote E, Fox-Robichaud A, Ainswoth C, Karachi T, Kyeremanteng K, Zarychanski R, Whitlock R, Rochwerg B. Tranexamic acid in cardiac surgery: a systematic review and meta-analysis (protocol). BMJ Open 2019; 9:e028585. [PMID: 31530593 PMCID: PMC6756438 DOI: 10.1136/bmjopen-2018-028585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Bleeding during cardiac surgery is associated with increased morbidity and mortality. Tranexamic acid is an antifibrinolytic with proven efficacy in major surgeries. Current clinical practice guidelines recommend intraoperative use in cardiac procedures. However, several complications have been reported with tranexamic acid including seizures. This review intends to summarise the evidence examining the efficacy and safety of tranexamic acid in patients undergoing cardiac surgery. METHODS/DESIGN We will search MEDLINE, Embase, PubMED, ACPJC, CINAHL and the Cochrane trial registry for eligible randomised controlled trials, the search dates for all databases will be from inception until 1 January 2019, investigating the perioperative use of topical and/or intravenous tranexamic acid as a stand-alone antifibrinolytic agent compared with placebo in patients undergoing open cardiac surgery. We categorised outcomes as patient critical or patient important. Selected patient-critical outcomes are: mortality (intensive care unit, hospital and 30-day endpoints), reoperation within 24 hours, postoperative bleeding requiring transfusion of packed red blood cells, myocardial infarction, stroke, pulmonary embolism, bowel infarction, upper or lower limb deep vein thrombosis and seizures. Those outcomes, we perceived as clinical experts to be most patient valued and patients were not involved in outcomes selection process. We will not apply publication date, language, journal or methodological quality restrictions. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria and then review full reports of all potentially relevant citations. A third reviewer will resolve disagreements if consensus cannot be achieved. We will present the results as relative risk with 95% CIs for dichotomous outcomes and as mean difference or standardised mean difference for continuous outcomes with 95% CIs. We will assess the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication TRIAL REGISTRATION NUMBER: CRD42018105904.
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Affiliation(s)
- Thamer Alaifan
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Ahmed Alenazy
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Dominic Xiang Wang
- Schulich School of Medicine and Dentistry, University of Western, London, Ontario, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Departments of Anesthesia and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Critical Care, Cardiology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Craig Ainswoth
- Department of Medicine, Critical Care, Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Critical Care, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine and of Hematology/Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
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Viktorsson SA, Vidisson KO, Gunnarsdottir AG, Helgason D, Johnsen A, Ingvarsdottir IL, Sigurdsson MI, Geirsson A, Gudbjartsson T. Improved long-term outcome of surgical AVR for AS: Results from a population-based cohort. J Card Surg 2019; 34:1235-1242. [PMID: 31472025 DOI: 10.1111/jocs.14238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this retrospective study was to determine changes in outcomes after surgical aortic valve replacement (SAVR) for aortic stenosis (AS) in Iceland over a 15-year period. METHODS We included 587 patients who underwent SAVR for AS in Iceland during the period 2002-2016, with a total follow-up of 3245 patient-years. Short-term and long-term outcomes, 30-day mortality, and long-term survival (Kaplan-Meier) were analyzed. Univariate linear regression and univariate and multinomial logistic regression analyses were performed on preoperative and perioperative variables. Poisson regression analysis was used to evaluate changes in rates of short-term outcomes. RESULTS Mean age was 71 years, 65.1% were males, and mean EuroSCORE II was 3.9. Mean preoperative aortic valve area increased significantly (0.013 cm2 /year; P < .001) and mean aortic cross-clamp time declined (108 minutes, 2.8 min/year; P < .001). The rate of complications decreased, including new-onset atrial fibrillation (60.9% overall, decreased by 3.1%/year, P = .02), acute kidney injury (17.1%, 7.6%/year, P < .001), and reoperation for bleeding (12.5%, 6.3%/year, P = .02). Operative mortality did not change (5.4%); nor did 1- and 5-year overall survival (92.5% and 81.6%, respectively). Notable long-term events were chronic heart failure (27.7 admissions/100 patient-years), embolic event (15.9/100 patient-years), and bleeding (13.0/100 patient-years). CONCLUSIONS Results of SAVR in this well-defined nationwide cohort of patients in Iceland have improved. This may be related to the patients having less severe AS at the time of operation and shorter operating times, as reflected by lower rates of short-term complications. However, the rate of long-term complications did not change significantly, with prosthetic valve-specific events being rare.
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Affiliation(s)
| | | | | | - Dadi Helgason
- Division of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Arni Johnsen
- Division of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Martin Ingi Sigurdsson
- Division of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tomas Gudbjartsson
- Division of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Knapik P, Knapik M, Zembala MO, Przybyłowski P, Nadziakiewicz P, Hrapkowicz T, Cieśla D, Deja M, Suwalski P, Jasiński M, Tobota Z, Maruszewski BJ, Zembala M, Anisimowicz L, Biederman A, Borkowski D, Brykczyński M, Bugajski P, Cholewiński P, Cichoń R, Cisowski M, Deja M, Dziatkowiak A, Gryszko LA, Gburek T, Haponiuk I, Hendzel P, Hirnle T, Jabłonka S, Jarmoszewicz K, Jasiński M, Jaszewski R, Jemielity M, Kalawski R, Kapelak B, Kaperczak J, Karolczak MA, Krejca M, Kustrzycki W, Kuśmierczyk M, Kwinecki P, Maruszewski B, Missima M, Ogorzeja JJMW, Pająk J, Pawliszak W, Pietrzyk E, Religa G, Rogowski J, Różański J, Sadowski J, Sharma G, Skalski J, Skiba J, Stążka J, Stępiński P, Suwalski K, Suwalski P, Tobota Z, Tułecki Ł, Widenka K, Wojtalik M, Woś S, Zembala M, Żelazny P. In-hospital and mid-term outcomes in patients reoperated on due to bleeding following coronary artery surgery (from the KROK Registry). Interact Cardiovasc Thorac Surg 2019; 29:237–243. [PMID: 30968119 DOI: 10.1093/icvts/ivz089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Surgical re-exploration due to postoperative bleeding that follows coronary artery surgery is associated with significant morbidity and mortality. The aim of this study was to assess a relationship between re-exploration, major postoperative complications, in-hospital mortality and mid-term outcomes in patients following coronary surgery, on the basis of nationwide registry data. METHODS We identified all consecutive patients enrolled in Polish National Registry of Cardiac Surgical Procedures (KROK Registry) who underwent isolated coronary surgery between January 2012 and December 2014. Preoperative data, major postoperative complications, hospital mortality and mid-term all-cause mortality were, respectively, analysed. Comparisons were performed in all patients, low-risk patients (EuroSCORE II < 2%, males, aged 60-70 years) and propensity-matched patients. The starting point for follow-up was the date of hospital discharge. RESULTS Among 41 353 analysed patients, 1406 (3.4%) underwent re-exploration. Reoperated patients had more comorbidities, more frequent major postoperative complications, higher in-hospital mortality (13.2% vs 1.8%, P < 0.001) and higher mid-term mortality in survivors (P < 0.001). In the low-risk population, 3.0% of patients underwent re-exploration. Reoperated low-risk patients and propensity-matched patients also had more frequent major postoperative complications and higher in-hospital mortality, but mid-term mortality in survivors was similar. In a multivariable analysis, re-exploration was an independent predictor of death and all major postoperative complications. CONCLUSIONS Surgical re-exploration due to postoperative bleeding following coronary artery surgery carries a high risk of perioperative mortality and is linked to major postoperative complications. Among patients who survive to hospital discharge, mid-term mortality is associated primarily with preoperative comorbidities.
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Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Małgorzata Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Michał O Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Piotr Przybyłowski
- Division of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Centre for Heart Diseases, Zabrze, Poland.,First Department of General Surgery, Jagiellonian University, Medical College, Cracow, Poland
| | - Paweł Nadziakiewicz
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Upper-Silesian Medical Centre, Medical University of Silesia, Katowice, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marek Jasiński
- Department of Cardiac Surgery, University Teaching Hospital, Wrocław, Poland
| | - Zdzisław Tobota
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan J Maruszewski
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
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Al-Attar N, Johnston S, Jamous N, Mistry S, Ghosh E, Gangoli G, Danker W, Etter K, Ammann E. Impact of bleeding complications on length of stay and critical care utilization in cardiac surgery patients in England. J Cardiothorac Surg 2019; 14:64. [PMID: 30940172 PMCID: PMC6444533 DOI: 10.1186/s13019-019-0881-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background Bleeding is a significant complication in cardiac surgery and is associated with substantial morbidity and mortality. This study evaluated the impact of bleeding on length of stay (LOS) and critical care utilization in a nationwide sample of cardiac surgery patients treated at English hospitals. Methods Retrospective, observational cohort study using linked English Hospital Episode Statistics (HES) and Clinical Practice Research Datalink (CPRD) records for a nationwide sample of patients aged ≥18 years who underwent coronary artery bypass graft (CABG), valve repair/replacement, or aortic operations from January 2010 through February 2016. The primary independent variables were in-hospital bleeding complications and reoperation for bleeding before discharge. Generalized linear models were used to quantify the adjusted mean incremental difference [MID] in post-procedure LOS and critical care days associated with bleeding complications, independent of measured baseline characteristics. Results The study included 7774 cardiac surgery patients (3963 CABG; 2363 valve replacement/repair; 160 aortic procedures; 1288 multiple procedures, primarily CABG+valve). Mean LOS was 10.7d, including a mean of 4.2d in critical care. Incidences of in-hospital bleeding complications and reoperation for bleeding were 6.7 and 0.3%, respectively. Patients with bleeding had longer LOS (MID: 3.1d; p < 0.0001) and spent more days in critical care (MID: 2.4d; p < 0.0001). Reoperation for bleeding was associated with larger increases in LOS (MID = 4.0d; p = 0.002) and days in critical care (MID = 3.2d; p = 0.001). Conclusions Among English cardiac surgery patients, in-hospital bleeding complications were associated with substantial increases in healthcare utilization. Increased use of evidence-based strategies to prevent and manage bleeding may reduce the clinical and economic burden associated with bleeding complications in cardiac surgery. Electronic supplementary material The online version of this article (10.1186/s13019-019-0881-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nawwar Al-Attar
- Department of Cardiac Surgery, Golden Jubilee National Hospital, University of Glasgow, Agamemnon St, Clydebank G81 4DY, Glasgow, UK.
| | - Stephen Johnston
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Nadine Jamous
- Health Economics & Market Access, Johnson & Johnson Medical Ltd, Berkshire, UK
| | - Sameer Mistry
- Medical Affairs, Johnson & Johnson Medical Ltd, Berkshire, UK
| | | | - Gaurav Gangoli
- Health Economics & Market Access, Ethicon, Somerville, NJ, USA
| | - Walter Danker
- Health Economics & Market Access, Ethicon, Somerville, NJ, USA
| | - Katherine Etter
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
| | - Eric Ammann
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, NJ, USA
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Anders M, Rock P, Cartron A, Chow J, Henderson R, Martz D, Tanaka K, Mazzeffi M. Isolated platelet concentrate transfusion during surgery: a single‐center observational cohort study. Transfusion 2019; 59:1661-1666. [DOI: 10.1111/trf.15156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Megan Anders
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Peter Rock
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Alex Cartron
- University of Maryland School of Medicine Baltimore Maryland
| | - Jonathan Chow
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Reney Henderson
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Douglas Martz
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Kenichi Tanaka
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Michael Mazzeffi
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
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36
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Dimberg A, Alström U, Janiec M. Re-exploration for bleeding associated with increased incidence of the need for reintervention after coronary artery bypass graft surgery. Interact Cardiovasc Thorac Surg 2018; 28:214-221. [DOI: 10.1093/icvts/ivy245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 07/05/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Axel Dimberg
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - Ulrica Alström
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - Mikael Janiec
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
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Thomas L, Woon E, Fong E, Parnaby C, Watson HG. Reducing the use of inappropriate coagulation testing in emergency general surgical patients. Scott Med J 2018; 63:45-50. [DOI: 10.1177/0036933018760762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and aims Indiscriminate coagulation testing in emergency general surgical patients can lead to inappropriate delay in surgery, cause unnecessary concern and is associated with significant cost. The British Committee for Standards in Haematology recommends against coagulation testing to predict peri-operative bleeding risk in unselected patients. Our aim was to assess the appropriateness of coagulation tests performed in emergency general surgical patients and evaluate the effect of a series of educational interventions on clinical practice. Methods and results Appropriate indications for performing coagulation testing included a positive bleeding history, the presence of liver disease/cholestasis, sepsis or use of anticoagulants. Initial data on 142 patients were collected over 2 weeks of receiving. Following analysis, indications for appropriate coagulation testing were highlighted and data were collected on a further 190 patients. Comparing the audit cycles, we observed a decrease in the proportion of patients who underwent routine testing (49.3% vs 32.6%; p = 0.002) and inappropriate testing (67% of tests vs 34% of tests; p < 0.001). Despite being highlighted, there was no evidence of improved documentation of bleeding histories on admission. Conclusions This observational study suggests that simple educational messages can reduce the inappropriate use of coagulation screening tests in general surgical emergencies. This seems to result from clarification of the appropriate surgical indications for coagulation testing in this group.
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Affiliation(s)
- Lydiya Thomas
- Core Medical Trainee, Department of General Surgery, Aberdeen Royal Infirmary, Scotland
| | - EeLaine Woon
- Foundation Year 2 Trainee, Department of General Surgery, Aberdeen Royal Infirmary, Scotland
| | - Elizabeth Fong
- Core Medical Trainee, Department of General Surgery, Aberdeen Royal Infirmary, Scotland
| | - Craig Parnaby
- Consultant Surgeon, Department of General Surgery, Aberdeen Royal Infirmary, Scotland
| | - Henry G Watson
- Consultant Haematologist, Department of Haematology, Aberdeen Royal Infirmary, Scotland
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Ohmes LB, Di Franco A, Guy TS, Lau C, Munjal M, Debois W, Li Z, Krieger KH, Schwann AN, Leonard JR, Girardi LN, Gaudino M. Incidence, risk factors, and prognostic impact of re-exploration for bleeding after cardiac surgery: A retrospective cohort study. Int J Surg 2018; 48:166-173. [PMID: 29104127 DOI: 10.1016/j.ijsu.2017.10.073] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postoperative re-exploration for bleeding (RB) is a frequent complication following cardiac surgery. We aim to assess incidence, risk factors, and prognostic significance of RB in a large cohort of cardiac patients. MATERIALS AND METHODS We reviewed prospectively collected data for all patients who underwent cardiac surgery at our institution from 2007 to 2015. Logistic regression analysis was used to identify independent predictors of RB and specific outcomes. Propensity matching using a 1:1-ratio compared outcomes of patients who had RB with patients who did not. RESULTS During the study period, 7381 patients underwent cardiac operations. Of them, 189 (2.6%) underwent RB. RB was an independent predictor of in-hospital mortality (Odds Ratio (OR):2.62 Confidence Interval (CI):1.38-4.96; p = 0.003), major adverse events (OR:3.94, CI:2.79-5.62; p < 0.001), gastrointestinal events (OR:3.54 CI:1.73-7.24), renal failure (OR:2.44, CI:1.23-4.82), prolonged ventilation (OR:3.83, CI:2.60-5.62, p < 0.001), and sepsis (OR:2.50, CI:1.03-6.04, p = 0.043). Preoperative shock (OR:3.68, CI:1.66-8.13; p = 0.001), congestive heart failure (OR:1.70 CI:1.24-2.32; p = 0.001), and urgent and emergent status (OR:2.27, CI:1.65-3.12 and OR:3.57, CI:1.89-6.75; p < 0.001 for both) were predictors of RB operative mortality. Operative mortality, incidence of major adverse events, gastrointestinal events, and respiratory failure were all significantly higher in the propensity matched RB group (p = 0.050, p < 0.001, p = 0.046, and p < 0.001 respectively). CONCLUSIONS RB significantly increases in-hospital mortality and morbidity after cardiac surgery.
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Affiliation(s)
- Lucas B Ohmes
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - T Sloane Guy
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Monica Munjal
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - William Debois
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Zhongyi Li
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Karl H Krieger
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Alexandra N Schwann
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Jeremy R Leonard
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, United States.
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Dimberg A, Alström U, Ståhle E, Christersson C. Higher Preoperative Plasma Thrombin Potential in Patients Undergoing Surgery for Aortic Stenosis Compared to Surgery for Stable Coronary Artery Disease. Clin Appl Thromb Hemost 2018; 24:1282-1290. [PMID: 29768939 PMCID: PMC6714769 DOI: 10.1177/1076029618776374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) influence the coagulation system, potentially affecting hemostasis during cardiac surgery. Our aim was to evaluate 2 preoperative global hemostasis assays, plasma thrombin potential and thromboelastometry, in patients with severe aortic valve stenosis compared to patients with CAD. A secondary aim was to test whether the assays were associated with postoperative bleeding. Calibrated automated thrombogram (CAT) in platelet-poor plasma and rotational thromboelastometry (ROTEM) in whole blood were analyzed in patients scheduled for elective surgery due to severe AS (n = 103) and stable CAD (n = 68). Patients with AS displayed higher plasma thrombin potential, both thrombin peak with median 252 nmol/L (interquartile range 187-319) and endogenous thrombin potential (ETP) with median 1552 nmol/L/min (interquartile range 1340-1838), when compared to patients with CAD where thrombin peak was median 174 nmol/L (interquartile range 147-229) and ETP median 1247 nmol/L/min (interquartile range 1034-1448; both P < .001). Differences persisted after adjustment for age, gender, comorbidity, and antithrombotic treatment. Differences observed in thromboelastometry between the groups did not persist after adjustment for baseline characteristics. Bleeding amount showed no relationship with plasma thrombin potential but weakly to thromboelastometry (R2 = .064, P = .001). Patients with AS exhibited preoperatively increased plasma thrombin potential compared to patients with CAD. Plasma thrombin potential was not predictive for postoperative bleeding in patients scheduled for elective surgery.
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Affiliation(s)
- Axel Dimberg
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrica Alström
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabeth Ståhle
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Reyes Garcia A, Vega González G, Andino Ruiz R. Short-term outcome of cardiac surgery under cardiopulmonary bypass in patients who refuse transfusion: a controlled study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:729-736. [PMID: 29616523 DOI: 10.23736/s0021-9509.18.10335-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although bloodless cardiac surgery has been successfully performed for many years, studies with controls permitting transfusion are few and their results inconclusive. This study compares the outcome of cardiac surgery on Jehovah's Witnesses (JW) refusing transfusion, with that of controls permitting transfusion if required. METHODS Data from 172 operations in 162 JW were compared with 172 matched controls. Risk factors, preoperative, operative, 48 hour postoperative variables, outcome data and transfusions were recorded. RESULTS Preoperative and operative variables were similar in both groups except for more previous cardiac operations, and more frequent use of cell saver and aprotinin in JW, who bled less and had higher hemoglobin concentrations at all periods. Thirty-day mortality was higher in JW (9.9% vs. 3.5%; P=0.03) (Risk difference 6.4%; CI95%: 2.7-10.1). Nevertheless operative mortality was similar in both groups (9.9% vs. 7.6%; P=0.44). Mortality in low-risk subjects was higher in JW (8.9% vs. 1.0%; P=0.02) (Risk difference 7.9%; CI95%: 2.7-13.2). Moreover, death associated with hemorrhage and anemia tended to be more frequent in JW. Mortality of transfused controls (14.1%) and their matched JW (13.0%) was similar. In contrast, mortality of non-transfused controls was zero versus 6.3% in their matched JW (P=0.059). CONCLUSIONS Low-risk JW had significantly higher mortality than controls. Bleeding related deaths tended to be more frequent in JW. Blood-sparing maneuvers should be intensively implemented in both JW and patients permitting transfusion in order to reduce bleeding and the need for transfusion with its harmful effects.
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Affiliation(s)
- Antonio Reyes Garcia
- Unit of Intensive Care, Hospital Universitario de la Princesa, Instituto de Investigación La Princesa, Madrid, Spain -
| | - Gema Vega González
- Unit of Intensive Care, Hospital Universitario de la Princesa, Instituto de Investigación La Princesa, Madrid, Spain
| | - Ricardo Andino Ruiz
- Unit of Intensive Care, Hospital Universitario de la Princesa, Instituto de Investigación La Princesa, Madrid, Spain
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Biancari F, Kinnunen EM, Kiviniemi T, Tauriainen T, Anttila V, Airaksinen JKE, Brascia D, Vasques F. Meta-analysis of the Sources of Bleeding after Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 32:1618-1624. [PMID: 29338997 DOI: 10.1053/j.jvca.2017.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to pool data on the proportion and prognostic impact of sources of bleeding in patients requiring re-exploration after adult cardiac surgery. DESIGN Systematic review of the literature and meta-analysis. SETTING Multistitutional study. MEASUREMENTS AND MAIN RESULTS A literature review was performed to identify studies published since 1990 evaluating the outcome after reoperation for bleeding or tamponade after adult cardiac surgery. Eighteen studies including 5,1497 patients fulfilled the selection criteria. Reoperation for bleeding/tamponade was performed in 2,455 patients (4.6%; 95% confidence interval [CI] 3.9%-5.2%, I2 92%). These had a significantly higher risk of in-hospital/30-day mortality compared with patients not reoperated for bleeding (pooled rates: 9.3% v 2.3%; risk ratio 3.30; 95% CI 2.52-4.32; I2 47%; 8 studies; 25,463 patients). Surgical sites of bleeding were identified in 65.7% of cases (95% CI 58.3%-73.2%; I2 94%), cardiac site bleeding in 40.9% of cases (95% CI 29.7%-52.0%; I2 94%), and mediastinal/sternum site bleeding in 27.0% of cases (95% CI 16.8%-37.3%; I2 94%). The main sites of bleeding were the body of the graft (20.2%), the sternum (17.0%), vascular sutures (12.5%), the internal mammary artery harvest site (13.0%), and anastomoses (9.9%). In metaregression, surgical site bleeding was associated with a lower risk of in-hospital/30-day mortality compared with diffuse bleeding (p = 0.003). CONCLUSIONS Surgical site bleeding is identified in two-thirds of patients undergoing re-exploration after adult cardiac surgery. Meticulous surgical technique and systematic intraoperative checking of potential surgical sites of bleeding at the time of the original cardiac surgery may reduce the risk of such a severe complication.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland; Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
| | | | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Vesa Anttila
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Debora Brascia
- Department of Surgery, University of Turku, Turku, Finland
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How detrimental is reexploration for bleeding after cardiac surgery? J Thorac Cardiovasc Surg 2017; 154:927-935. [DOI: 10.1016/j.jtcvs.2016.04.097] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 03/28/2016] [Accepted: 04/05/2016] [Indexed: 11/22/2022]
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Rashed A, Gombocz K, Vigh A, Alotti N. Total proximal anastomosis detachment after classical bentall procedure. Int J Surg Case Rep 2017; 37:173-176. [PMID: 28688312 PMCID: PMC5501880 DOI: 10.1016/j.ijscr.2017.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/05/2017] [Accepted: 06/11/2017] [Indexed: 11/28/2022] Open
Abstract
Total proximal anastomosis detachment after classical Bentall procedure is very rare and life-threatrning complication. Elongation of the left ventricle tract may serve a surgical solution to treat this complication. Surgeons performing the Bentall procedure must be familiar with all existing modifications.
Introduction Since its introduction in 1968, the Bentall procedure has been the primary surgical solution for aneurysms of the aortic root. However, many surgeons have reported serious procedural complications such as detachment of coronary ostia and pseudoaneurysm formation at anastomosis sites. Therefore, the Bentall procedure has undergone several modifications to eliminate those complications. Partial or total detachment of the proximal anastomosis is rarely reported. Presentation of case We report a total detachment of the proximal anastomosis after a Bentall operation with emphasis on the possible practical mechanisms, which might have led to the development of this very rare complication. The diagnosis was confirmed at a routine follow up examination and urgent surgery was performed. We also report our operative solution and review other possible surgical solutions that might be considered in this setting. Discussion The Bentall procedure and its modifications continue to be considered the gold standard for treating aneurysms involving the aortic root. Various modifications can serve as optimal solutions for procedure-related complications. Conclusion Surgeons performing the Bentall procedure must be familiar with all existing modifications because they are complementary to the original surgical procedure. In the absence of endocarditis left ventricle outflow tract elongation may be an acceptable surgical solution to deal with total detachment of the proximal anastomosis.
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Affiliation(s)
- Aref Rashed
- Department of Cardiac Surgery, Zala St. Raphael County Hospital, Zalaegerszeg, Hungary.
| | - Karoly Gombocz
- Department of Cardiac Surgery, Zala St. Raphael County Hospital, Zalaegerszeg, Hungary
| | - Andras Vigh
- Department of Cardiac Surgery, Zala St. Raphael County Hospital, Zalaegerszeg, Hungary
| | - Nasri Alotti
- Department of Cardiac Surgery, Zala St. Raphael County Hospital, Zalaegerszeg, Hungary
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Wang M, Chen M, Ao H, Chen S, Wang Z. The Effects of Different BMI on Blood Loss and Transfusions in Chinese Patients Undergoing Coronary Artery Bypass Grafting. Ann Thorac Cardiovasc Surg 2017; 23:83-90. [PMID: 28179605 DOI: 10.5761/atcs.oa.16-00219] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Blood loss is a predictor of outcomes after coronary artery bypass grafting (CABG). This study investigated the effects of body mass index (BMI) on blood loss, blood transfusion rate, and the variations in coagulation parameters of Chinese patients undergoing CABG. METHODS A total of 1007 Chinese patients who consecutively underwent isolated, primary CABG at Fuwai Hospital from January 1, 2013 to December 31, 2013 were included in this study. They were categorized by BMI into <24 kg/m2 (low and normal weight group), 24≤ BMI <28 kg/m2 (overweight group), and BMI ≥28 kg/m2 (obese group). Following this BMI classification, the quantities of blood lost and recorded transfusions were analyzed. RESULTS Blood loss and transfusion rates were significantly higher in the low and normal weight group compared with the obese group (p <0.01). Chest tube drainage over 24 h, duration of intensive care unit (ICU) stay, and postoperative mechanical ventilation were higher as well (p <0.01). Atrial fibrillation was closely related to blood transfusion (p <0.001). CONCLUSIONS Obesity is a predictor for protection against blood loss and transfusion in Chinese people. Patients with low and normal BMI lost more blood per kg of their weight and had higher total transfused volume during isolated primary CABG. Atrial fibrillation was associated with high blood transfusion.
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Affiliation(s)
- Mingya Wang
- Department of Anesthesiology and Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ming Chen
- Erduosi Hospital, Inner Mongolia, China
| | - Hushan Ao
- Department of Anesthesiology and Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sipeng Chen
- Department of Anesthesiology and Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Almashrafi A, Vanderbloemen L. Quantifying the effect of complications on patient flow, costs and surgical throughputs. BMC Med Inform Decis Mak 2016; 16:136. [PMID: 27769228 PMCID: PMC5073872 DOI: 10.1186/s12911-016-0372-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Postoperative adverse events are known to increase length of stay and cost. However, research on how adverse events affect patient flow and operational performance has been relatively limited to date. Moreover, there is paucity of studies on the use of simulation in understanding the effect of complications on care processes and resources. In hospitals with scarcity of resources, postoperative complications can exert a substantial influence on hospital throughputs. METHODS This paper describes an evaluation method for assessing the effect of complications on patient flow within a cardiac surgical department. The method is illustrated by a case study where actual patient-level data are incorporated into a discrete event simulation (DES) model. The DES model uses patient data obtained from a large hospital in Oman to quantify the effect of complications on patient flow, costs and surgical throughputs. We evaluated the incremental increase in resources due to treatment of complications using Poisson regression. Several types of complications were examined such as cardiac complications, pulmonary complications, infection complications and neurological complications. RESULTS 48 % of the patients in our dataset experienced one or more complications. The most common types of complications were ventricular arrhythmia (16 %) followed by new atrial arrhythmia (15.5 %) and prolonged ventilation longer than 24 h (12.5 %). The total number of additional days associated with infections was the highest, while cardiac complications have resulted in the lowest number of incremental days of hospital stay. Complications had a significant effect on perioperative operational performance such as surgery cancellations and waiting time. The effect was profound when complications occurred in the Cardiac Intensive Care (CICU) where a limited capacity was observed. CONCLUSIONS The study provides evidence supporting the need to incorporate adverse events data in resource planning to improve hospital performance.
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Affiliation(s)
- Ahmed Almashrafi
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus, Reynolds Building, St Dunstans Road, London, W6 8RP UK
| | - Laura Vanderbloemen
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus, Reynolds Building, St Dunstans Road, London, W6 8RP UK
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46
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Rafiq S, Johansson PI, Kofoed KF, Olsen PS, Steinbrüchel DA. Preoperative hemostatic testing and the risk of postoperative bleeding in coronary artery bypass surgery patients. J Card Surg 2016; 31:565-71. [DOI: 10.1111/jocs.12807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Sulman Rafiq
- Department of Cardiothoracic Surgery; the Heart Centre, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Pär I. Johansson
- Capital Region Blood Bank; Section for Transfusion Medicine, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Klaus F. Kofoed
- Department of Cardiology; the Heart Centre, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Peter S. Olsen
- Department of Cardiothoracic Surgery; the Heart Centre, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Daniel A. Steinbrüchel
- Department of Cardiothoracic Surgery; the Heart Centre, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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47
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Petrou A, Tzimas P, Siminelakis S. Massive bleeding in cardiac surgery. Definitions, predictors and challenges. Hippokratia 2016; 20:179-186. [PMID: 29097882 PMCID: PMC5654433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Severe or massive bleeding in cardiac surgery is an uncommon but important clinical scenario. Its existing definitions are diverse. Its characteristics constantly change during an active hemorrhage and, thus is difficult to define appropriately. METHODS In this narrative, non-systematic review, we performed a literature search to retrieve data that could contribute to answering clinical questions on the definition and grading of severe hemorrhage and massive transfusion, identifying factors that predict and affect bleeding and transfusion-related mortality and describing the risks of re-exploration and the economic impact of severe bleeding in cardiac surgery. Results: Massive perioperative bleeding is currently described by indices of its rate and extent and the magnitude of the consequent blood products transfusion. It has a significant impact on mortality, service logistics, and hospital financing. Proper and early identification of a massive bleeding is possible. Among other factors, patient's co-morbidities, bleeding severity and transfusion volume seem to predict the associated mortality. Consequent to severe bleeding, re-exploration, is also a potentially hazardous adverse event that also affects morbidity and mortality. CONCLUSIONS Severe perioperative hemorrhage in cardiac surgery carries significant morbidity and mortality. Currently, prediction and identification of massive bleeding is a feasible but incomplete clinical task despite the availability of effective treatment regimens. A still missing, compact definition of massive perioperative bleeding in cardiac surgery that incorporates all phases of treatment could augment clinical preparedness, allow for the development of accurate prediction tools and permit the application of well-validated protocols of management. Hippokratia 2016, 20(3): 179-186.
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Affiliation(s)
- A Petrou
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Hellas
| | - P Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Hellas
| | - S Siminelakis
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Hellas
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Van Poucke S, Stevens K, Wetzels R, Kicken C, Verhezen P, Theunissen M, Kuiper G, van Oerle R, Henskens Y, Lancé M. Early platelet recovery following cardiac surgery with cardiopulmonary bypass. Platelets 2016; 27:751-757. [PMID: 27164510 DOI: 10.3109/09537104.2016.1173665] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) is frequently associated with low platelet count (PC) and disturbed platelet function (PF). While PC is easy to measure, PF is more difficult to assess. Moreover, the time-related platelet dysfunction and recovery after CPB is not fully elucidated. Platelet dysfunction could lead to bleeding but also to coronary graft failure. Laboratory tests could provide more insights into PF after CABG. The aim of the current study was to investigate the time-related PF induced by CPB. Blood samples of 20 patients with a preoperative PC of more than 250 × 109/L were collected before incision, after weaning from CPB, and 24 h postoperative. Platelet contribution to coagulation was quantified by PLTEM (calculated by means of EXTEM and FIBTEM results). PF was assessed by multiple electrode impedance aggregometry (MEIA) in whole blood and by light transmission aggregometry (LTA) in platelet-rich plasma after stimulation with arachidonic acid (AA), adenosine diphosphate, collagen, and thrombin-receptor-activating peptide. LTA and MEIA analysis demonstrated significant platelet dysfunction after CPB, with partial recovery within 24 h after surgery. AA-induced platelet aggregation increased to higher levels within 24 h after surgery compared to baseline values as measured by LTA. PLTEM maximum clot firmness remained unchanged throughout the study. Correlation analyses revealed that MEIA and rotational thromboelastometry (ROTEM), but not LTA, were dependent on PC and hematocrit. No correlations were found between LTA, MEIA, ROTEM, PC, and clinical outcome parameters. Our results demonstrate a reversible platelet dysfunction recovering within 24 h after CPB. Interestingly, AA-induced platelet aggregation increases to higher levels during the first 24 h postoperatively, which might be important for early initiation of antiplatelet therapy after CABG. MEIA as POC test is able to detect platelet dysfunction during cardiac surgery with a PC of ≥150 × 109/L.
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Affiliation(s)
- Sven Van Poucke
- a Department of Anaesthesiology , Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg (ZOL) , Genk , Belgium
| | - Kris Stevens
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Rick Wetzels
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Cécile Kicken
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Paul Verhezen
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Maurice Theunissen
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Gerhardus Kuiper
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Rene van Oerle
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Yvonne Henskens
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Marcus Lancé
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,d Department of Intensive Care , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
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Petricevic M, Konosic S, Biocina B, Dirkmann D, White A, Mihaljevic MZ, Ivancan V, Konosic L, Svetina L, Görlinger K. Bleeding risk assessment in patients undergoing elective cardiac surgery using ROTEM®platelet and Multiplate®impedance aggregometry. Anaesthesia 2016; 71:636-47. [DOI: 10.1111/anae.13303] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2015] [Indexed: 11/29/2022]
Affiliation(s)
- M. Petricevic
- University of Zagreb School of Medicine; Department of Cardiac Surgery; University Hospital Centre Zagreb; Zagreb Croatia
| | - S. Konosic
- Department of Anesthesiology; University Hospital Centre Zagreb; Zagreb Croatia
| | - B. Biocina
- University of Zagreb School of Medicine; Department of Cardiac Surgery; University Hospital Centre Zagreb; Zagreb Croatia
| | - D. Dirkmann
- Klinik für Anästhesiologie und Intensivmedizin; Universität Duisburg-Essen; Universitätsklinikum Essen; Essen Germany
| | - A. White
- University of Zagreb School of Medicine; Department of Cardiac Surgery; University Hospital Centre Zagreb; Zagreb Croatia
| | - M. Z. Mihaljevic
- University of Zagreb School of Medicine; Department of Cardiac Surgery; University Hospital Centre Zagreb; Zagreb Croatia
| | - V. Ivancan
- Department of Anesthesiology; University Hospital Centre Zagreb; Zagreb Croatia
| | - L. Konosic
- University of Zagreb School of Medicine; Department of Cardiac Surgery; University Hospital Centre Zagreb; Zagreb Croatia
| | - L. Svetina
- University of Zagreb School of Medicine; Department of Cardiac Surgery; University Hospital Centre Zagreb; Zagreb Croatia
| | - K. Görlinger
- Klinik für Anästhesiologie und Intensivmedizin; Universität Duisburg-Essen; Universitätsklinikum Essen; Essen Germany
- TEM International GmbH; Munich Germany
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50
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Ozolina A, Strike E, Nikitina-Zake L, Jaunalksne I, Krumina A, Lacis R, Bjertnaes LJ, Vanags I. Polymorphisms on PAI-1 and ACE genes in association with fibrinolytic bleeding after on-pump cardiac surgery. BMC Anesthesiol 2015; 15:122. [PMID: 26340801 PMCID: PMC4560913 DOI: 10.1186/s12871-015-0101-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 08/26/2015] [Indexed: 12/11/2022] Open
Abstract
Background Carriers of plasminogen activator inhibitor -1 (PAI-1) -675 genotype 5G/5G may be associated with lower preoperative PAI-1 plasma levels and higher blood loss after heart surgery using cardiopulmonary bypass (CPB). We speculate if polymorphisms of PAI-1 -844 A/G and angiotensin converting enzyme (ACE) intron 16 I/D also might promote fibrinolysis and increase postoperative bleeding. Methods We assessed PAI-1 -844 A/G, and ACE intron 16 I/D polymorphisms by polymerase chain reaction technique and direct sequencing of genomic DNA from 83 open heart surgery patients that we have presented earlier. As primary outcome, accumulated chest tube drainage (CTD) at 4 and 24 h were analyzed for association with genetic polymorphisms. As secondary outcome, differences in plasma levels of PAI-1, t-PA/PAI-1 complex and D-dimer were determined for each polymorphism. SPSS® was used for statistical evaluation. Results The lowest preoperative PAI-1 plasma levels were associated with PAI-1 -844 genotype G/G, and higher CTD, as compared with genotype A/A at 4 and 24 h after surgery. Correspondingly, 4 h after the surgery CTD was higher in carriers of ACE intron 16 genotype I/I, as compared with genotype D/D. PAI-1 plasma levels and t-PA/PAI-1 complex reached nadir in carriers of ACE intron 16 genotype I/I, in whom we also noticed the highest D-dimer levels immediately after surgery. Notably, carriers of PAI-1 -844 genotype G/G displayed higher D-dimer levels at 24 h after surgery as compared with those of genotype A/G. Conclusions Increased postoperative blood loss secondary to enhanced fibrinolysis was associated with carriers of PAI-1 -844 G/G and ACE Intron 16 I/I, suggesting that these genotypes might predict increased postoperative blood loss after cardiac surgery using CPB. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0101-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Agnese Ozolina
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Eva Strike
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Liene Nikitina-Zake
- Latvian Biomedical Research and Study Center, Ratsupites Street 1, Riga, Latvia.
| | - Inta Jaunalksne
- Clinical Immunology Centre, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia.
| | - Angelika Krumina
- Department of Infectology and Dermatology, Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Romans Lacis
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway.
| | - Indulis Vanags
- Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
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