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Wang J, Hou J, Feng K, Wu H, Liu Q, Zhou Z, Li H, Luo L, Fu G, Shang L, Chen G, Huang S, Wu Z. Development and validation of a postoperative bleeding complications prediction model in infective endocarditis. Int J Cardiol 2024; 396:131432. [PMID: 37827281 DOI: 10.1016/j.ijcard.2023.131432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/23/2023] [Accepted: 10/08/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES Bleeding complications are one of the most serious postoperative complications after cardiac surgery and are associated with high mortality, especially in patients with infective endocarditis (IE). Our objectives were to identify the risk factors and develop a prediction model for postoperative bleeding complications in IE patients. METHODS The clinical data of IE patients treated from October 2013 to January 2022 were reviewed. Multivariate logistic regression analysis was used to evaluate independent risk factors for postoperative bleeding complications and develop a prediction model accordingly. The prediction model was verified in a temporal validation cohort. The performance of the model was evaluated in terms of its discrimination power, calibration, precision, and clinical utility. RESULTS A total of 423 consecutive patients with IE who underwent surgery were included in the final analysis, including 315 and 108 patients in the training cohort and validation cohort, respectively. Four variables were selected for developing a prediction model, including platelet counts, systolic blood pressure, heart failure and vegetations on the mitral and aortic valves. In the training cohort, the model exhibited excellent discrimination power (AUC = 0.883), calibration (Hosmer-Lemeshow test, P = 0.803), and precision (Brier score = 0.037). In addition, the model also demonstrated good discrimination power (AUC = 0.805), calibration (Hosmer-Lemeshow test, P = 0.413), and precision (Brier score = 0.067) in the validation cohort. CONCLUSIONS We developed and validated a promising risk model with good discrimination power, calibration, and precision for predicting postoperative bleeding complications in IE patients.
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Affiliation(s)
- Junjie Wang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Hou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kangni Feng
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huawei Wu
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Quan Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huayang Li
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li Luo
- Department of Cardiac Surgery, First Affiliated Hospital of Xi'an Jiaotong University, China
| | - Guangguo Fu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liqun Shang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guangxian Chen
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Cardiothoracic Surgery ICU, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Lawrence KW, Yin K, Connelly HL, Datar Y, Brydges H, Balasubramaniyan R, Karlson KJ, Edwards NM, Dobrilovic N. Sex-based outcomes in surgical repair of acute type A aortic dissection: A meta-analysis and meta-regression. J Thorac Cardiovasc Surg 2024; 167:76-85.e13. [PMID: 35331557 DOI: 10.1016/j.jtcvs.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/08/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Epidemiologic variation with respect to sex has been established in aortic dissection. However, current literature on sex-based outcomes in patients with aortic dissection is conflicting. In this study we aimed to compare perioperative outcomes according to sex in patients treated surgically for acute type A aortic dissection. METHODS PubMed/MEDLINE, Embase, and Web of Science were searched for studies that reported sex-based differences in postoperative outcomes among patients with acute type A aortic dissection. The primary outcome was in-hospital/30-day mortality, and secondary outcomes included postoperative stroke, renal failure requiring dialysis, and reoperation for bleeding. Data were aggregated using the random effects model as pooled risk ratio (RR). Meta-regression was applied to identify sources of heterogeneity between studies. RESULTS Nine of 1022 studies were included for final analysis comprising 3338 female and 5979 male participants. Compared with male sex, female sex was associated with similar in-hospital/30-day mortality (RR, 1.04; 95% CI, 0.85-1.28; P = .67), postoperative stroke risk (RR, 1.07; 95% CI, 0.91-1.25; P = .43), and postoperative risk of acute renal failure requiring dialysis (RR, 0.84; 95% CI, 0.59-1.19; P = .32). A decreased risk of reoperation for bleeding (RR, 0.84; 95% CI, 0.75-0.94; P < .01) was observed in female participants. Meta-regression analysis indicated that differences in preoperative shock were a source of heterogeneity in the sex difference in in-hospital/30-day mortality across studies. CONCLUSIONS Among patients treated surgically for acute type A aortic dissection, female sex was not associated with increased risk of short-term mortality nor with major postoperative complications. Male sex was associated with a greater risk of postoperative bleeding.
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Affiliation(s)
- Kyle W Lawrence
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Kanhua Yin
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Haley L Connelly
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Yesh Datar
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Hilliard Brydges
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Ramkumar Balasubramaniyan
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Karl J Karlson
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Niloo M Edwards
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Nikola Dobrilovic
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass; Division of Cardiac Surgery, NorthShore University HealthSystem, Chicago, Ill.
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Mathieu L, Beurton A, Rougier N, Flambard M, Germain C, Pernot M, Ouattara A. Heparin consumption and inflammatory response according to the coating of cardiopulmonary bypass circuits in cardiac surgery: A retrospective analysis. Perfusion 2023:2676591231215282. [PMID: 37944166 DOI: 10.1177/02676591231215282] [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: 11/12/2023]
Abstract
INTRODUCTION There are several types of surface treatments (coatings) aimed at improving the biocompatibility of cardiopulmonary bypass (CPB) circuit. Some coatings appear to require higher doses of heparin to maintain anticoagulation goals, and some of them might induce postoperative coagulopathy. In this study, we compared the amount of heparin required, postoperative bleeding, and inflammatory response according to three types of coatings. METHOD We retrospectively included 300 consecutive adult patients who underwent cardiac surgery with CPB and received one of three coatings (Phisio®, Trillium®, and Xcoating™). Our primary objective was to compare, according to coating, the amount of heparin required to maintain an ACT > 400s during CPB. Our secondary objectives were to compare postoperative bleeding for 48 h and CRP rate. RESULTS Baseline characteristics were comparable between groups except for age and preoperative CRP. We did not find a significant difference between the 3 coatings regarding the amount of heparin reinjected. However, we found less postoperative bleeding with the Xcoating™ circuit compared to the Phisio® circuit (-149 mL [-289; -26.5]; p = 0.02) and a lower elevation of CRP with the Phisio® circuit (2.8 times higher than preoperative CRP) compared to Trillium® (4.9 times higher) and Xcoating™ (6.4 times higher); p < 10-3. CONCLUSION The choice of coating did not influence the amount of heparin required during CPB; however, the post-CPB inflammatory syndrome may be impacted by this choice.
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Affiliation(s)
- Laurent Mathieu
- Department of Cardiovascular Surgery, Haut-Lévêque Hospital, Surgical Centre, Bordeaux University Hospital, Pessac, France
| | - Antoine Beurton
- Department of Cardiovascular Anesthesia and Critical Care, Haut-Lévêque Hospital, Bordeaux University Hospital, Bordeaux, France
- Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaires, U1034, F-33600 Pessac, France
| | - Nicolas Rougier
- Department of Cardiovascular Surgery, Haut-Lévêque Hospital, Surgical Centre, Bordeaux University Hospital, Pessac, France
| | - Maude Flambard
- Department of Cardiovascular Surgery, Haut-Lévêque Hospital, Surgical Centre, Bordeaux University Hospital, Pessac, France
| | - Christine Germain
- Research and Innovation Unit in Healthcare and Humanities (URISH), Bordeaux-University Hospital, Bordeaux, France
| | - Mathieu Pernot
- Department of Cardiovascular Surgery, Haut-Lévêque Hospital, Surgical Centre, Bordeaux University Hospital, Pessac, France
| | - Alexandre Ouattara
- Department of Cardiovascular Anesthesia and Critical Care, Haut-Lévêque Hospital, Bordeaux University Hospital, Bordeaux, France
- Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaires, U1034, F-33600 Pessac, France
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Yao X, Li N, Lu R, Wang X, Zhang Y, Wang S. Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery. J Clin Nurs 2023; 32:1466-1475. [PMID: 35988041 DOI: 10.1111/jocn.16489] [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: 05/13/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To construct a predictive nomogram of the risk of nosocomial infections among patients after cardiac valve replacement surgery. BACKGROUND Nosocomial infections are a standout challenge that worsens the prognosis of patients after valve replacement surgery. However, studies on the nomogram of nosocomial infections in these patients have remained scarce. DESIGN A retrospective cohort study. METHODS Patients (n = 720) following valve replacement surgery from 2018 to 2019 were selected. LASSO regression and multivariate logistic regression were utilised to ascertain predictors of nosocomial infections. The predictive performance of the nomogram was appraised by calibration and discrimination. Decision and impact curves were used to assess the clinical utility. Internal validation was implemented via 1000 bootstrap samples to mitigate overfitting. TRIPOD guidelines were used in this study. RESULTS One hundred and fifty one patients (20.97%) experienced nosocomial infections following valve replacement surgery. Heart failure, preoperative anaemia, valve material, American Society of Anesthesiologists score ≥ IV, prolonged duration of surgery, duration of mechanical ventilation ≥ 24 h and indwelling nasogastric tube were predictors of nosocomial infections. Using these variables, we developed a predictive nomogram of the occurrence of nosocomial infections and the internal validation results demonstrated good discrimination and calibration of the nomogram. The clinical decision and impact curve revealed significant clinical utility. CONCLUSIONS The present study constructed a nomogram for predicting the risk of nosocomial infections in patients following cardiac valve replacement surgery. This nomogram may strengthen the effective screening of patients at high risk of nosocomial infections. RELEVANCE TO CLINICAL PRACTICE This risk warning tool can assist clinical staff in making decisions and providing individualised infection control measures for patients, which has a significant reference value for clinical practice. NO PATIENT OR PUBLIC CONTRIBUTION The data for this study were obtained from the hospital database, and the entire process of the study did not involve patient participation.
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Affiliation(s)
- Xue Yao
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Na Li
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Ranran Lu
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Xujing Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Yujun Zhang
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Shuhui Wang
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
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Benson JW, Hraska V, Scott JP, Stuth EAE, Yan K, Zhang J, Niebler RA. Comparison of Prothrombin Complex Concentrate with Activated Factor VII Use for Bleeding Following Cardiopulmonary Bypass in Children. World J Pediatr Congenit Heart Surg 2023; 14:282-288. [PMID: 36919404 DOI: 10.1177/21501351231162911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE This study aims to compare the efficacy and safety of activated recombinant factor VII (rFVIIa) and prothrombin complex concentrate (PCC) in the treatment of bleeding complications following surgery requiring cardiopulmonary bypass (CPB) in children. DESIGN/METHODS This is a retrospective chart review of a single institution comprising patients aged 0 to 18 years old with congenital heart disease. Patients must have received either PCC or rFVIIa after coming off CPB. Our primary efficacy endpoint is time in the operating room from off-CPB to pediatric intensive care unit admission. Our primary safety endpoint is thrombosis through 30 days. RESULTS Our primary efficacy outcome was significantly shorter in the PCC group compared with the rFVIIa group (P < .0001). Similarly, secondary efficacy outcomes of packed red blood cell administration, chest tube output, and transfusion exposures all significantly favored PCC administration. However, CPB time was significantly longer, and body temperatures were significantly lower, in the rFVIIa group. Safety outcomes, including our primary safety outcome of thrombosis through 30 days, were similar between the two groups. CONCLUSION This study questions whether PCC could be favored over rFVIIa for hemostasis in children with congenital heart disease following CPB surgery. In addition, this study has found no difference when comparing PCC and rFVIIa in terms of safety outcomes, particularly thrombosis events. There are several limitations to this study due to the retrospective nature of the design and the differences between the two study groups. Despite the limitations, this study suggests that relatively early administration of PCC could be favored over delayed administration of rFVIIa to control recalcitrant post-CPB bleeding in the operating room.
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Affiliation(s)
- John W Benson
- Division of Pediatric Critical Care, Department of Pediatrics, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Viktor Hraska
- Division of Congenital Heart Surgery and Herma Heart Institute, Department of Surgery, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA.,Division of Pediatric Critical Care, Department of Pediatrics, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA
| | - Eckehard A E Stuth
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA
| | - Ke Yan
- Section of Quantitative Health Sciences, Department of Pediatrics, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jian Zhang
- Section of Quantitative Health Sciences, Department of Pediatrics, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Niebler
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA
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Zubarevich A, Szczechowicz M, Arjomandi Rad A, Amanov L, Ruhparwar A, Weymann A. Conventional Biological versus Sutureless Aortic Valve Prostheses in Combined Aortic and Mitral Valve Replacement. Life (Basel) 2023; 13:life13030737. [PMID: 36983892 PMCID: PMC10056806 DOI: 10.3390/life13030737] [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: 01/09/2023] [Revised: 02/03/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Sutureless aortic valve prostheses have proven to provide a significant decrease in procedural, cardiopulmonary bypass and cross-clamp time, leading to a significant reduction in mortality risk in elderly high-risk cohorts. In this study, we sought to review our institutional experience on the sutureless aortic valve replacement (SU-AVR) and the concomitant mitral valve replacement (SMVR), comparing the combined conventional surgical aortic valve replacement (SAVR) with SMVR. METHODS AND MATERIAL Between March 2018 and July 2022, 114 consecutive patients underwent a combined aortic and mitral valve replacement at our institution. We stratified the patients according to the operative procedures into two groups and matched them 1:2: Group 1 underwent a combined conventional SAVR and SMVR (n = 46), and Group 2 included combined SU-AVR with Perceval prosthesis and SMVR (n = 23). RESULTS No significant differences in the preoperative characteristics were present. SU-AVR combined with SMVR demonstrated excellent haemodynamic performance, comparable to that of SAVR plus SMVR, with median postoperative gradients over the aortic valve of 4 mmHg (IQR 3.0-4.0) in Group 1 and 4 mmHg (IQR 3.0-4.0) in Group 2 (p = 0.67). There was no significant difference in the occurrence of postoperative major adverse events such as death, stroke, myocardial infarction and kidney failure between the groups. There was also no significant difference in the permanent pacemaker implantation rate, paravalvular leakage or valve dislocation. We also could not detect any significant difference in postoperative mortality between the groups. CONCLUSIONS SU-AVR has proven to be a reliable alternative to conventional valve prostheses in patients with multivalve disease undergoing combined aortic and mitral valve replacement, offering shorter procedural time and outstanding hemodynamic performance compared to the conventional surgical method.
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Affiliation(s)
- Alina Zubarevich
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
| | - Marcin Szczechowicz
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
| | | | - Lukman Amanov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
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Li X, Wang R, Sun D, Yao Y, Wang T, Luo G, Liu M, Xu J, Cheng Z, Gao Q, Wang Y, Wu C, Xu G, Lv T, Zou J, Yan M. Risk Factors for Hypocoagulability After Cardiac Surgery: A Retrospective Study. Clin Appl Thromb Hemost 2023; 29:10760296231209927. [PMID: 37933155 PMCID: PMC10631354 DOI: 10.1177/10760296231209927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023] Open
Abstract
Hemostatic disturbances after cardiac surgery can lead to excessive postoperative bleeding. Thromboelastography (TEG) was employed to evaluate perioperative coagulative alterations in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), investigating the correlation between factors concomitant with cardiac surgery and modifications in coagulation. Coagulation index as determined by TEG correlated significantly with postoperative bleeding at 24-72 h after cardiac surgery (P < .001). Among patients with a normal preoperative coagulation index, those with postoperative hypocoagulability showed significantly lower nadir temperature (P = .003), larger infused fluid volume (P = .003), and longer CPB duration (P = .033) than those with normal coagulation index. Multivariate logistic regression showed that nadir intraoperative temperature was an independent predictor of postoperative hypocoagulability (adjusted OR: 0.772, 95% CI: 0.624-0.954, P = .017). Multivariate linear regression demonstrated linear associations of nadir intraoperative temperature (P = .017) and infused fluid volume (P = .005) with change in coagulation index as a result of cardiac surgery. Patients are susceptible to hypocoagulability after cardiac surgery, which can lead to increased postoperative bleeding. Ensuring appropriate temperature and fluid volume during cardiac surgery involving CPB may reduce risk of postoperative hypocoagulability and bleeding.
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Affiliation(s)
- Xuejie Li
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong, China
| | - Ruiyu Wang
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong, China
| | - Dawei Sun
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yuanyuan Yao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tingting Wang
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ge Luo
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mingxia Liu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingpin Xu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhenzhen Cheng
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qi Gao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Wang
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chaomin Wu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guangxin Xu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tao Lv
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingcheng Zou
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Min Yan
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong, China
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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8
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Little C, Odho Z, Szydlo R, Aw T, Laffan M, Arachchillage DRJ. Impact of aspirin on bleeding and blood product usage in off-pump and on-pump coronary artery bypass graft surgery. EJHAEM 2022; 3:317-325. [PMID: 35846054 PMCID: PMC9175687 DOI: 10.1002/jha2.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 11/21/2022]
Abstract
Major bleeding is linked to poorer outcomes following cardiac surgery. Current guidelines recommend continuation of aspirin prior to coronary artery by-pass graft (CABG) but the effect of continuing aspirin in patients with prior indication for aspirin, in particular during off-pump CABG (OPCABG), has not been systematically assessed. In this study, we analysed the effect of continuing aspirin prior to OPCABG and on-pump CABG with respect to bleeding and blood product usage. We compared propensity-matched cohorts of patients who continued aspirin until the day of OPCABG or CABG to controls (no antiplatelet) and to patients discontinuing aspirin 5-7 days prior. Length of hospital stay, 30-day mortality and thromboembolism rates were similar for both OPCABG and CABG. During OPCABG, aspirin-continued patients received more intraoperative red cell units compared to controls without difference in bleeding. Aspirin-continued patients received more blood products perioperatively and bled more than aspirin-discontinued patients undergoing OPCABG. The only difference during CABG was a small increase in the volume of cells salvaged among aspirin-continued patients compared to controls. Current guidelines on the continuation of aspirin prior to CABG and OPCABG are safe. Continuation of aspirin prior to OPCABG may result in more bleeding and blood product usage.
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Affiliation(s)
- Christopher Little
- Centre for Haematology, Department of Immunology and InflammationImperial College LondonLondonUK
| | - Zain Odho
- Department of Biochemistry, Royal Brompton & Harefield HospitalsPart of Guy's & St Thomas’ NHS Foundation TrustLondonUK
| | - Richard Szydlo
- Centre for Haematology, Department of Immunology and InflammationImperial College LondonLondonUK
| | - Tuan‐Chen Aw
- Department of AnaesthesiaRoyal Brompton Hospital & Harefield NHS Foundation TrustLondonUK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and InflammationImperial College LondonLondonUK
- Department of HaematologyImperial College Healthcare NHS Trust Imperial College LondonLondonUK
| | - Deepa R. J. Arachchillage
- Centre for Haematology, Department of Immunology and InflammationImperial College LondonLondonUK
- Department of HaematologyImperial College Healthcare NHS Trust Imperial College LondonLondonUK
- Department of HaematologyRoyal Brompton HospitalLondonUK
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9
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Perek B, Rzymski P, Komosa A, Olasińska-Wiśniewska A, Puślecki M, Jemielity M, Lesiak M, Aboul-Hassan SS, Stankowski T, Xia Z, Stelmark K, Siller-Matula J, Poniedziałek B. Mean platelet volume-to-platelet count ratio after elective cardiac surgical procedures is superior in reflecting platelets metabolic hyperactivity compared to other routine morphological platelet indices: A preliminary report. Cardiol J 2021; 30:VM/OJS/J/83339. [PMID: 34787889 PMCID: PMC10713209 DOI: 10.5603/cj.a2021.0150] [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: 05/16/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Excessive metabolic excitation of platelets after cardiac procedures may be related to some adverse events but assessment of their metabolic activity is not routine. The purpose of this study was to evaluate which of the basic platelet morphological parameters best reflects their metabolic status. METHODS The blood samples of 22cardiac surgical patients (mean age of 62.3 ± 10.3 years) were taken before surgery (BS), and 1, 24 and 48 hours after the operation. Correlations between morphological platelet parameters (platelet count [PLT], mean platelet volume [MPV], platelet distribution width [PDW] and MPV/PLT) and their metabolic activity (total concentration of malondialdehyde [MDA] and MDA/PLT) were estimated. RESULTS Significant decline in PLT after operation (from 223 ± 44 × 10¹²/L to 166 ± 57 × 10¹²/L) was accompanied by marked increase in MPV (from 8.4 ± 0.9 fL to 9.1 ± 1.2 fL) and no change of PDW. Consequently, MPV/PLT index increased significantly after procedures from (median with IQR) 0.038 (0.030-0.043) to 0.053 (0.043-0.078). Simultaneously, a significant increase in total platelet MDA content and MDA/PLT was noted reaching peak levels soon after operation. The strongest correlation was observed between MPV/PLT and MDA/PLT (r = 0.56; p < 0.001), although the others were also found to be significant (MDA/PLT vs. MPV; r = 0.35; MDA/PLT vs. PDW; r = 0.34). CONCLUSIONS Among basic morphological parameters and indices, the MPV-to-PLT ratio reflects the best metabolic status of platelets in cardiac surgical patients.
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Affiliation(s)
- Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland.
| | - Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Integrated Science Association (ISA), Universal Scientific Education and Research Network (USERN)
| | - Anna Komosa
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poland
| | - Anna Olasińska-Wiśniewska
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puślecki
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
- Department of Medical Rescue, Poznan University of Medical Sciences, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poland
| | - Sleiman Sebastian Aboul-Hassan
- Department of Cardiac Surgery, Medinet Heart Center Ltd, Nowa Sol, Poland
- Department of Cardiac Surgery and Interventional Cardiology, Faculty of Medicine and Medical Sciences, University of Zielona Gora, Zielona Gora, Poland
| | | | - Zhengyuan Xia
- Shenzhen Institute of Research and Innovation, The University of Hong Kong, China
| | - Konrad Stelmark
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Jolanta Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Barbara Poniedziałek
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland
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10
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Vlot EA, van Dongen EPA, Willemsen LM, Berg JMT, Hackeng CM, Loer SA, Noordzij PG. Association of Plasma Fibrinogen and Thromboelastography With Blood Loss in Complex Cardiac Surgery. Clin Appl Thromb Hemost 2021; 27:10760296211016541. [PMID: 34013768 PMCID: PMC8142233 DOI: 10.1177/10760296211016541] [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] [Indexed: 11/16/2022] Open
Abstract
Postoperative coagulopathic bleeding is common in cardiac surgery and is
associated with increased morbidity and mortality. Ideally, real-time
information on in-vivo coagulation should be available. However, up to now it is
unclear which perioperative coagulation parameters can be used best to
accurately identify patients at increased risk of bleeding. The present study
analyzed the associations of perioperative fibrinogen concentrations and whole
blood viscoelastic tests with postoperative bleeding in 89 patients undergoing
combined cardiac surgery procedures. Postoperative bleeding was recorded until
24 hours after surgery. Regression analyses were performed to establish
associations between blood loss and coagulation parameters after cardiopulmonary
bypass including a prediction model with known confounding factors for bleeding.
Coagulation tests show large changes over the perioperative course with the
strongest coagulopathic deviations from baseline after cardiopulmonary bypass.
After adjustment for multiple confounders, viscoelastic clot strength instead of
fibrinogen concentration showed a similar performance for 24 hour blood loss and
a better performance for 6 hour blood loss. This makes intraoperative
viscoelastic testing a useful tool to strengthen early clinical decision-making
with the potential to reduce perioperative blood transfusions.
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Affiliation(s)
- Eline A Vlot
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric P A van Dongen
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jur M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christian M Hackeng
- Department of Clinical Chemistry, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Stephan A Loer
- Department of Anaesthesia, Intensive Care and Pain Medicine, Amsterdam UMC, The Netherlands
| | - Peter G Noordzij
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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11
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Finch LM, Baltatzis M, Byott S, Ganapathy AK, Kakani N, Lake E, Cadwallader R, Hazar C, Seriki D, Butterfield S, Jegatheeswaran S, Jamdar S, de Liguori Carino N, Siriwardena AK. Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage. ANNALS OF SURGERY OPEN 2021; 2:e038. [PMID: 37638254 PMCID: PMC10455063 DOI: 10.1097/as9.0000000000000038] [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: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage. Methods This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage. Results Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days). Conclusions This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.
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Affiliation(s)
- Louise M. Finch
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Minas Baltatzis
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Sam Byott
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Nirmal Kakani
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Edward Lake
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Rosemary Cadwallader
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Can Hazar
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Dare Seriki
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Stephen Butterfield
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Santhalingam Jegatheeswaran
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Saurabh Jamdar
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Nicola de Liguori Carino
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ajith K. Siriwardena
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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12
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Bastopcu M, Özhan A, Erdoğan SB, Kehlibar T. Factors associated with excessive bleeding following elective on-pump coronary artery bypass grafting. J Card Surg 2021; 36:1277-1281. [PMID: 33484200 DOI: 10.1111/jocs.15364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Excessive bleeding following cardiac surgery is associated with worse outcomes. We aimed to analyze preoperative and operative factors associated with excessive bleeding in coronary artery bypass patients to better understand which patients are under increased risk. METHODS The study was conducted as an observational study in a tertiary center for cardiac surgery by retrospective analysis of the hospital database. Patients were grouped according to chest tube output within the postoperative 24 h. Patients in the 4th percentile of chest tube output per kilogram were categorized as having excessive bleeding. Patients with excessive bleeding were compared with the other patients for preoperative and operative factors. Factors significant in univariate analysis were carried onto the multivariate analysis. RESULTS Patients with excessive bleeding were more likely to be males (91.4% vs. 78.7%, p = .002), have lower body mass index (BMI) (27.4 vs. 29.2, p < .001), and low platelets (6.9% vs. 1.5%, p = .006). Cardiopulmonary bypass (101.8 vs. 110.9 min, p = .022) time was longer in the excessive bleeding group. Patients with excessive bleeding were more likely to have more than three vessels revascularized. Male sex, lower BMI, low platelets, and longer cardiopulmonary bypass time were independently associated with increased bleeding. CONCLUSION Male sex, lower BMI, low platelet count, and longer cardiopulmonary bypass time are associated with extensive bleeding after elective coronary artery bypass surgery (CABG). Patients with higher bleeding risk should be identified preoperatively to account for adverse outcomes after CABG.
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Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Abdulkerim Özhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç B Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tamer Kehlibar
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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13
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Abstract
Objectives To investigate the effect of albumin exposure in ICU after cardiac surgery on hospital mortality, complications, and costs. Design A retrospective, single-center cohort study with economic evaluation. Setting Cardiothoracic ICU in Australia. Patients Adult patients admitted to the ICU after cardiac surgery. Interventions None. Measurements and Main Results Comparison of outcomes and costs in ICU after cardiac surgery based on 4% human albumin exposure. During the study period, 3,656 patients underwent cardiac surgery. After exclusions, 2,594 patients were suitable for analysis. One-thousand two-hundred sixty-four (48.7%) were exposed to albumin and 19 (1.4%) of those died. The adjusted hospital mortality of albumin exposure compared with no albumin was not significant (odds ratio, 1.24; 95% CI, 0.56-2.79; p = 0.6). More patients exposed to albumin returned to the operating theater for bleeding and/or tamponade (6.1% vs 2.1%; odds ratio, 2.84; 95% CI, 1.81-4.45; p < 0.01) and received packed red cell transfusions (p < 0.001). ICU and hospital lengths of stay were prolonged in those exposed to albumin (mean difference, 18 hr; 95% CI, 10.3-25.6; p < 0.001 and 87.5 hr; 95% CI, 40.5-134.6; p < 0.001). Costs (U.S. dollar) were higher in patients exposed to albumin, compared with those with no albumin exposure (mean difference in ICU costs, $2,728; 95% CI, $1,566-3,890 and mean difference in hospital costs, $5,427; 95% CI, $3,294-7,560). Conclusions There is no increased mortality in patients who are exposed to albumin after cardiac surgery. The patients exposed to albumin had higher illness severity, suffered more complications, and incurred higher healthcare costs. A randomized controlled trial is required to determine whether albumin use is effective and safe in this setting.
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14
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Gunertem E, Urcun S, Pala AA, Budak AB, Ercisli MA, Gunaydin S. Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery. Perfusion 2020; 36:277-284. [DOI: 10.1177/0267659120941327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. Methods: The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. Results: Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. Conclusion: Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.
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Affiliation(s)
- Eren Gunertem
- Department of Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Salim Urcun
- Department of Cardiovascular Surgery, Adiyaman Training and Research Hospital, Adiyaman, Turkey
| | - Arda Aybars Pala
- Department of Cardiovascular Surgery, Adiyaman Training and Research Hospital, Adiyaman, Turkey
| | - Ali Baran Budak
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | | | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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15
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Little C, Szydlo R, Aw TC, Laffan M, Arachchillage DRJ. Effect of direct-acting oral anticoagulants (DOACs) on bleeding and blood product usage in cardiac surgery compared to warfarin and controls. Br J Haematol 2020; 190:284-293. [PMID: 32128791 DOI: 10.1111/bjh.16521] [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: 11/24/2019] [Accepted: 01/12/2020] [Indexed: 11/30/2022]
Abstract
In this retrospective, single-centre, observational study, we assessed (i) use of anticoagulant and antiplatelet (AP) therapy, (ii) the duration of direct-acting oral anticoagulant (DOAC) discontinuation, (iii) renal function and (iv) PT and APTT as predictors of bleeding and blood product usage; in adults (>18 years) undergoing major cardiac surgery from 01.01.2015 to 31.12.2018. Comparisons were made between each treatment group (warfarin, DOAC and DOAC + AP) and untreated controls, and between warfarin and DOAC. A total of 2928 patients were included for analysis. Median (range) of DOAC discontinuation prior to surgery was five days (1-22) for DOAC and five days (2-7) for DOAC + AP. There were no differences in bleeding between anticoagulant groups versus control, or DOAC versus warfarin. There were no differences in blood product use between DOAC and warfarin patients. The duration of DOAC discontinuation but not the creatinine clearance influenced bleeding and blood products use. Thrombosis occurred in 0·7% and 3·1% in controls and patients on warfarin respectively (P = 0·099) with none among patients on DOAC or DOAC + AP. The PT/APTT had no predictive value. Median five-day discontinuation of DOAC +/- AP irrespective of renal function prevents an increase in bleeding compared to patients on warfarin or controls with no increase in thrombosis.
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Affiliation(s)
- Christopher Little
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Richard Szydlo
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - T C Aw
- Department of Anaesthesia, Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Deepa R J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Department of Haematology, Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
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16
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Meesters MI, von Heymann C. Optimizing Perioperative Blood and Coagulation Management During Cardiac Surgery. Anesthesiol Clin 2019; 37:713-728. [PMID: 31677687 DOI: 10.1016/j.anclin.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Bleeding and transfusion are common in cardiac surgery and associated with poorer outcome. Bleeding is frequently due to coagulopathy caused by the complex interaction between cardiopulmonary bypass, major surgical trauma, anticoagulation management, and perioperative factors. Patient blood management has emerged to improve outcome by the prediction, prevention, monitoring, and treatment of bleeding and transfusion. Each part of this chain has several individual modalities and when combined leads to result in a better outcome. This article reviews the hemostasis disturbances in cardiac surgery with cardiopulmonary bypass and gives an overview of the most important patient blood management strategies.
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Affiliation(s)
- Michael Isaäc Meesters
- Department of Anesthesiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands.
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, Berlin 10249, Germany
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17
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Nwafor IA, Eze JC. Management of bleeding and blood transfusion in open cardiac surgery in a developing country: five-years institutional experience. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04904-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Reply to: aprotinin and coronary artery bypass surgery. Eur J Anaesthesiol 2019; 35:69-70. [PMID: 29658906 DOI: 10.1097/eja.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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van Valen R, van Gameren M, Mokhles MM, Takkenberg JJM, Ter Horst M, Hofland J, Bogers AJJC. Effectiveness of adherence to a preoperative antiplatelet and anticoagulation cessation protocol in cardiac surgery. Interact Cardiovasc Thorac Surg 2019; 26:820-825. [PMID: 29309597 DOI: 10.1093/icvts/ivx401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/19/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Reduction of blood loss after cardiac surgery remains challenging. The effectiveness of adherence to a protocol on cessation of anticoagulants and platelet-inhibiting medications was investigated together with the influence of protocol violations on blood loss after surgery, use of blood products, surgical re-explorations and 30-day mortality. METHODS Between 2009 and 2013, data were collected prospectively for all elective cardiac surgery procedures in adult patients (n = 1637). Two groups were distinguished: Group 1 adhered to the protocol for cessation or continuation of medication (n = 1287, 79%) and Group 2 violated the protocol (n = 350, 21%). RESULTS Median blood loss was 300 ml (interquartile range 175-500 ml). Eighty patients underwent re-exploration due to blood loss (5%). Thirty-day mortality was 2% (n = 27). Protocol violation was associated with increased blood loss [median 275 ml (175-475 ml) vs 350 ml (250-612); P ≤ 0.001] and with increased average use of fresh frozen plasma (226 ml vs 139 ml; P << 0.00001), red blood cell transfusion (115 ml vs 87 ml; P = 0.081) and thrombocyte transfusions (52 ml vs 37 ml; P = 0.0082). The number of re-explorations (4% vs 6%; P = 0.39) and mortality risk (1% vs 2%; P = 0.72) did not differ. CONCLUSIONS Balancing the benefit of continuing platelet inhibitors or anticoagulants versus cessation before surgery remains challenging. Adherence to the protocol will lead to lower blood loss and in a lower consumption of blood products although the decision to go for re-exploration and 30-day mortality does not differ compared with the protocol violation. Stopping medication does not lead to thromboembolic events.
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Affiliation(s)
- Richard van Valen
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Jan Hofland
- Department of Anesthesiology, Radboud UMC, Nijmegen, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
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20
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Braga DV, Brandão MAG. Diagnostic evaluation of risk for bleeding in cardiac surgery with extracorporeal circulation. Rev Lat Am Enfermagem 2018; 26:e3092. [PMID: 30517580 PMCID: PMC6280528 DOI: 10.1590/1518-8345.2523.3092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 09/17/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. METHOD case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. RESULTS variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). CONCLUSION such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.
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Affiliation(s)
- Damaris Vieira Braga
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Janeiro, RJ, Brazil
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21
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Utilisation of blood and blood products during open heart surgery in a low-income country: our local experience in 3 years. Cardiol Young 2018; 28:1289-1294. [PMID: 30070188 DOI: 10.1017/s1047951118001269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In Nigeria, access to open heart surgery (OHS) is adversely affected by insufficient blood and blood products, including the challenges because of the lack of patient-focused blood management strategies owing to the absent requisite point-of-care tests in the operating theatre (OR)/ICU. In addition, the limited availability of altruistic blood donors including the detection of transfusion transmitted infections more commonly among non-altruistic blood donors is another burden affecting the management of excessive bleeding during and after open heart surgery in our country. OBJECTIVE The objective of this study was to review our local experience in the use of blood and blood products during open heart surgery and compare the same with the literature.Materials and methodsIn a period of 3 years (March, 2013-February, 2016), we performed a retrospective review of those who had open heart surgery in our institution. The data were obtained from our hospital health information technology department. The data comprised demography, types of operative procedures and units of blood and blood products transfused per procedure, including the details regarding the usage of the cell saver, as well as those who had severe bleeding requiring excessive blood transfusion. RESULTS During the study period, 102 patients had open heart surgery, an average of 34 cases in a year. Among them, there were 75 (73.53%) males and 37 (36.27%) females, giving a ratio of 2:1. The ages of the patients were from 0.6 (7/12) to 74 years. Mitral valve procedure was the most common (n=22, 21.6%) surgery type. Transfusion requirements averaged 1.9 units of fresh frozen plasma, 0.36 units of platelet concentrate, and 1.68 units of packed cells per procedure. The least common surgical procedure was common atrium repair (n=1, 0.01%). CONCLUSION Open heart procedure is a very complex procedure requiring cardiopulmonary bypass with associated severe perioperative bleeding. The attendant blood loss and haemostatic challenges are combated by intricate and selective transfusions of allogeneic blood and or blood products.
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22
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Meesters MI, Burtman D, van de Ven PM, Boer C. Prediction of Postoperative Blood Loss Using Thromboelastometry in Adult Cardiac Surgery: Cohort Study and Systematic Review. J Cardiothorac Vasc Anesth 2018; 32:141-150. [DOI: 10.1053/j.jvca.2017.08.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/22/2022]
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23
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Wei XB, Jiang L, Liu YH, Feng D, He PC, Chen JY, Tan N, Yu DQ. Thrombocytopenia as a Preoperative Risk Assessment Tool in Patients With Rheumatic Heart Disease Undergoing Valve Replacement Surgery. J Am Heart Assoc 2017; 6:JAHA.117.006988. [PMID: 29203580 PMCID: PMC5779018 DOI: 10.1161/jaha.117.006988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative thrombocytopenia has been reported to be correlated with adverse events, but the prognostic value of baseline thrombocytopenia is unclear. This study was undertaken to evaluate the relationship between preoperative thrombocytopenia and adverse outcomes in patients with rheumatic heart disease who underwent valve replacement surgery. METHODS AND RESULTS A total of 1789 patients with rheumatic heart disease undergoing valve replacement surgery were consecutively enrolled and postoperatively followed up for 1 year. Patients were stratified on the basis of presence (n=495) or absence (n=1294) of thrombocytopenia (platelet count, <150×109/L), according to hospital admission platelet counts. During the hospitalization period, 69 patients (3.9%) died. The in-hospital all-cause mortality rate was significantly higher in the thrombocytopenic group (6.9% versus 2.7%; P<0.001). Multivariate analyses revealed that thrombocytopenia was independently associated with in-hospital all-cause mortality (odds ratio, 2.21; 95% confidence interval, 1.29-3.80; P=0.004). Platelet counts could predict in-hospital all-cause mortality for patients both with and without previous atrial fibrillation (areas under the curve, 0.708 [P<0.001] and 0.610 [P=0.025], respectively). One-year survival was significantly lower in patients with thrombocytopenia compared with controls (91.3% versus 96.1%; log-rank=14.65; P<0.001). In addition, thrombocytopenia was an independent predictor for postoperative 1-year all-cause mortality in multivariate Cox regression analysis. CONCLUSIONS Platelet counts, as simple and inexpensive indexes, were reliable to be used as a preoperative risk assessment tool for patients with rheumatic heart disease undergoing valve replacement surgery.
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Affiliation(s)
- Xue-Biao Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Lei Jiang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yuan-Hui Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Du Feng
- The Department of Developmental Biology, Harvard School of Dental Medicine, Harvard Medical School, Boston, MA
| | - Peng-Cheng He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ning Tan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Dan-Qing Yu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
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Levy JH, Grottke O, Fries D, Kozek-Langenecker S. Therapeutic Plasma Transfusion in Bleeding Patients. Anesth Analg 2017; 124:1268-1276. [DOI: 10.1213/ane.0000000000001897] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dos Santos ER, Lopes CT, Maria VLR, de Barros ALBL. Risk factors for decreased cardiac output after coronary artery bypass grafting: a prospective cohort study. Eur J Cardiovasc Nurs 2016; 16:352-359. [PMID: 27888199 DOI: 10.1177/1474515116681373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND No previous study has investigated the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after coronary artery bypass grafting (CABG). AIMS This study aimed to identify the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after CABG. METHODS This was a prospective cohort study performed at a cardiac university hospital in São Paulo, Brazil and 257 adult patients undergoing CABG were included. Potential risk factors for low cardiac output in the immediate post-operative period were investigated using the patients' medical records. Univariate analysis and logistic regression were used to identify the predictive risk factors of decreased cardiac output. The area under the receiver operating characteristic curve was calculated as a measure of accuracy. The variables that could not be analysed through logistic regression were analysed through Fisher's exact test. RESULTS One hundred and ninety-five patients had low cardiac output in the immediate post-operative period. The predictive risk factors included age ⩾60 years, decreased left ventricle ejection fraction, not using the radial artery graft, positive fluid balance and post-operative arrhythmia that differed from the pre-operative arrhythmia. This model predicted the outcome with a sensitivity of 62.9%, a specificity of 87.2% and an accuracy of 81.5%. The variables analysed through Fisher's exact test included heart failure, re-exploration and bleeding-related re-exploration. CONCLUSIONS The predictive risk factors for the nursing diagnosis of risk for decreased cardiac output after CABG were found. These results can be used to direct nurses in patient monitoring, staff training and nursing team staffing.
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Affiliation(s)
- Eduarda Ribeiro Dos Santos
- 1 Paulista Nursing School, Federal University of São Paulo (EPE-UNIFESP), Brazil.,2 Faculdade Israelita de Ciências da Saúde Albert Einstein, Brazil
| | - Camila Takao Lopes
- 1 Paulista Nursing School, Federal University of São Paulo (EPE-UNIFESP), Brazil
| | - Vera Lucia Regina Maria
- 1 Paulista Nursing School, Federal University of São Paulo (EPE-UNIFESP), Brazil.,3 Universidade São Camilo, Brazil
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Biancari F, Tauriainen T, Perrotti A, Dalén M, Faggian G, Franzese I, Chocron S, Ruggieri VG, Bounader K, Gulbins H, Reichart D, Svenarud P, Santarpino G, Fischlein T, Puski T, Maselli D, Dominici C, Nardella S, Mariscalco G, Gherli R, Musumeci F, Rubino AS, Mignosa C, De Feo M, Bancone C, Gatti G, Maschietto L, Santini F, Salsano A, Nicolini F, Gherli T, Zanobini M, Saccocci M, D'Errigo P, Kinnunen EM, Onorati F. Bleeding, transfusion and the risk of stroke after coronary surgery: A prospective cohort study of 2357 patients. Int J Surg 2016; 32:50-7. [DOI: 10.1016/j.ijsu.2016.06.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/10/2016] [Accepted: 06/15/2016] [Indexed: 01/16/2023]
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Lopes CT, Brunori EFR, Cavalcante AMRZ, Moorhead SA, Swanson E, Lopes JDL, de Barros ALBL. Factors associated with excessive bleeding after cardiac surgery: A prospective cohort study. Heart Lung 2016; 45:64-69.e2. [DOI: 10.1016/j.hrtlng.2015.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 09/13/2015] [Accepted: 09/14/2015] [Indexed: 12/23/2022]
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