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

Gender is Independently Associated With Red Blood Cell and Platelet Transfusion in Patients Undergoing Coronary Artery Bypass Grafting: Data From the Netherlands Heart Registration

OBJECTIVES

The aim of this study was to evaluate the incidence of transfusions, including red blood cells (RBC), platelets, and fresh frozen plasma (FFP) during and after coronary artery bypass grafting (CABG) in the Netherlands. Furthermore, the authors aimed to identify the impact of sex on blood product transfusion.

DESIGN

A retrospective multicenter cohort study. Data were collected from January 2013 to December 2021 from the Netherlands Heart Registration (NHR) database.

SETTING

The NHR receives its data from 16 heart centers in the Netherlands.

PARTICIPANTS

Patients older than 18 years who underwent CABG in the Netherlands.

INTERVENTIONS

Coronary artery bypass grafting with extracorporeal circulation or off-pump coronary artery bypass grafting.

MEASUREMENTS AND MAIN RESULTS

The incidence of blood transfusion, defined as transfusions intraoperatively and during the length of the hospital admission after CABG. In addition, a differentiation was made according to the type of transfusion (packed RBC, platelets, and FFP). In the overall cohort (N = 42,388), the number of patients who received a transfusion of any type was 27.0% (n = 11,428). Women received more often RBC transfusions compared with men (45.4% v 15.6%, respectively, p < 0.001). There was a significant difference between the 2 sexes regarding platelet transfusion (women 10.0% v men 11.1%, p = 0.005) but not in FFP transfusion. Female sex was independently associated with RBC transfusion, using the multivariate logistic regression analysis.

CONCLUSIONS

The incidence of any blood transfusion was 27.0%, and was higher in women than in men. The female sex was independently associated with receiving RBC during and after CABG.

Preoperative Anemia and Female Gender are Risk Factors for Transfusion in Patients Undergoing Coronary Artery Bypass Grafting with a Restrictive Transfusion Strategy

Objective

Red blood cell (RBC) transfusion in cardiac surgery is associated with increased morbidity and mortality. Even when using patient blood management methods, blood transfusions may still be needed in cardiac surgery. This study examined the risk factors for blood transfusion in isolated coronary artery bypass graft (CABG) surgery with a restrictive transfusion strategy, along with individualized patient blood management.

Methods

We enrolled 198 patients (age, 61.8 ± 9.9 years; 28 females and 170 males) who underwent isolated CABG surgery in a single private hospital using a restrictive transfusion strategy between April 2015 and October 2020. Pre-, intra-, and postoperative parameters were compared between patients with and without RBC transfusions. The risk factors for transfusion and transfusion probability were analyzed.

Results

Patients who received RBC transfusions had higher European System for Cardiac Operative Risk Evaluation values (13.60 ± 18.27%). Preoperative hematocrit (Hct) [odds ratio (OR)=0.752; 95% confidence interval (CI) 0.639-0.884; P=0.001] and female gender (OR=7.874; 95% CI 1.678-36.950; P=0.009) were significant independent risk factors for RBC transfusion in logistic regression analysis. When the preoperative Hct was 30%, the RBC transfusion probability was 61.08% in females and 16.6% in males. Patients who received RBC transfusions had longer intensive care unit (31.40 ± 25.42 hours) and hospital (11.18 ± 6.75 days) stays.

Conclusion

Risk factors for RBC transfusion in isolated CABG surgery with a restrictive blood transfusion strategy were preoperative anemia and female gender.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Register (ChiCTR2200065834).

Red blood cell transfusion induces abnormal HIF-1α response to cytokine storm after adult cardiac surgery

Patients undergoing cardiac surgery develop a marked postoperative systemic inflammatory response. Blood transfusion may contribute to disruption of homeostasis in these patients. We sought to evaluate the impact of blood transfusion on serum interleukin-6 (IL-6), hypoxia induced factor-1 alpha (HIF-1α) levels as well as adverse outcomes in patients undergoing adult cardiac surgery. We prospectively enrolled 282 patients undergoing adult cardiac surgery. Serum IL-6 and HIF-1α levels were measured preoperatively and on the first postoperative day. Packed red blood cells were transfused in 26.3% of patients (mean 2.93 ± 3.05 units) by the time of postoperative sampling. Postoperative IL-6 levels increased over 30-fold and were similar in both groups (p = 0.115), whilst HIF-1α levels (0.377 pg/mL vs. 0.784 pg/mL, p = 0.002) decreased significantly in patients who received red blood cell transfusion. Moreover, greater decrease in HIF-1α levels predicted worse in-hospital and 3mo adverse outcome. Red blood cell transfusion was associated with higher risk of major adverse outcomes (stroke, pneumonia, all-cause mortality) during the index hospitalization. Red blood cell transfusion induces blunting of postoperative HIF-1 α response and is associated with higher risk of adverse thrombotic and pulmonary adverse events after cardiac surgery.

Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03444259.