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Moussa MD, Soquet J, Robin E, Labreuche J, Rousse N, Rauch A, Loobuyck V, Leroy G, Duburcq T, Gantois G, Leroy X, Ait-Ouarab S, Lamer A, Thellier L, Lukowiak O, Schurtz G, Muller C, Juthier F, Susen S, Vincentelli A. Definitions of major bleeding for predicting mortality in critically ill adult patients who survived 24 hours while supported with peripheral veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: a comparative historical cohort study. Can J Anaesth 2024; 71:523-534. [PMID: 38438682 DOI: 10.1007/s12630-024-02704-6] [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: 09/25/2022] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 03/06/2024] Open
Abstract
PURPOSE The severity of bleeding events is heterogeneously defined during peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO). We studied three bleeding definitions in pVA-ECMO: the Extracorporeal Life Support Organization (ELSO)-serious bleeding, the Bleeding Academic Research Consortium (BARC), and the universal definition of postoperative bleeding (UPDB) classifications. METHODS We included consecutive adult patients supported by pVA-ECMO for refractory cardiogenic shock admitted to Lille academic hospitals between January 2013 and December 2019. We assessed the association of bleeding definitions with the primary endpoint of 28-day all-cause mortality with the use of multivariate models accounting for time-dependent and competing variables. We compared models' performances using the Harrell's C-Index and the Akaike information criteria. RESULTS Twenty-eight-day mortality occurred in 128/308 (42%) 308 patients. The ELSO-serious bleeding (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.09 to 2.56) and BARC ≥ type 2 (HR, 1.55; 95% CI, 1.01 to 2.37) were associated with 28-day mortality (Harrell's C-index, 0.69; 95% CI, 0.63 to 0.74 for both). Predictors of ELSO-serious bleeding were postcardiotomy, body mass index, baseline platelets count, fibrinogen, and hemoglobin levels. CONCLUSION Extracorporeal Life Support Organization-serious bleeding and BARC ≥ type 2 are relevant definitions of major bleeding regarding their association with mortality in critically ill patients who survived the first 24 hr while supported with pVA-ECMO for cardiogenic shock. STUDY REGISTRATION CERAR (IRB 00010254-2022-050, Paris, France); first submitted on 18 April 2022.
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Affiliation(s)
- Mouhamed D Moussa
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France.
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France.
- Service d'Anesthésie-Réanimation Cardiovasculaire et thoracique, Institut Cœur - Poumon, CHU Lille, 2 avenue Oscar Lambret, 59 037, Lille, France.
| | - Jérôme Soquet
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Emmanuel Robin
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Natacha Rousse
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Antoine Rauch
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Valentin Loobuyck
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | | | | | | | - Xavier Leroy
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Antoine Lamer
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | - Lise Thellier
- Pôle d'Anesthésie-Réanimation, CHU Lille, Lille, France
| | | | - Guillaume Schurtz
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiology, CHU Lille, Lille, France
| | | | - Francis Juthier
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
| | - Sophie Susen
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
| | - André Vincentelli
- Institut Pasteur de Lille, Université de Lille, Inserm, CHU Lille, Lille, France
- Department of Cardiac Surgery, CHU Lille, Lille, France
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Cui W, Zhang J, Wu Y, Yang W, Gao R, Yang Y, Yuan J, Zhao X. Novel Platelet Function Analyzer 200 Predicts Blood Transfusion After Elective Cardiac Surgery in Patients Suspended on Dual Antiplatelet Therapy. Clin Appl Thromb Hemost 2023; 29:10760296231187627. [PMID: 37563887 PMCID: PMC10422916 DOI: 10.1177/10760296231187627] [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: 05/14/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 08/12/2023] Open
Abstract
The value of platelet function test in timing of cardiac surgery remains uncertain. Researches on correlation between Platelet Function Analyzer 200 (PFA-200) and bleeding after elective cardiac surgery are still inadequate. The objective of this study was to investigate the predictive value of PFA-200 in blood transfusion after cardiac surgery. A total of 71 patients on aspirin and P2Y12 receptor inhibitors undergoing cardiac surgery in Fuwai Hospital were enrolled. Platelet function after discontinuing of antiplatelet drugs was assessed by PFA-200 using closure time (CT). PFA-200 results before surgery were included in the statistics. The primary endpoint was postoperative blood transfusion. Seventeen patients (21.9%) received blood transfusion after cardiac surgery. The preoperative PFA-200 CT value in the transfused group was significantly higher than that in the non-transfused group (147.24 ± 85.54 s vs 98.06 ± 61.59 s, P = .011). Using 106 seconds as the dividing point, the incidence of blood transfusion in the elevated PFA-200 (CT > 106 s) group was significantly higher than those in normal PFA-200 (CT ≤ 106 s) group (10/24 patients, 41.9% vs 7/47 patients, 14.7%, P = .012). Multivariate logistic regression analysis showed that PFA-200 CT value > 106 s was an independent predictor of postoperative blood transfusion (OR: 4.05, 95%CI: 1.19-13.86, P = .026). The platelet function test PFA-200 had a predictive value for postoperative blood transfusion in elective cardiac surgery and had a promising prospect in the timing of cardiac surgery.
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Affiliation(s)
- Wen Cui
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jun Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuan Wu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Weixian Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xueyan Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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3
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Gao Y, Liu X, Wang L, Wang S, Yu Y, Ding Y, Wang J, Ao H. Machine learning algorithms to predict major bleeding after isolated coronary artery bypass grafting. Front Cardiovasc Med 2022; 9:881881. [PMID: 35966564 PMCID: PMC9366116 DOI: 10.3389/fcvm.2022.881881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesPostoperative major bleeding is a common problem in patients undergoing cardiac surgery and is associated with poor outcomes. We evaluated the performance of machine learning (ML) methods to predict postoperative major bleeding.MethodsA total of 1,045 patients who underwent isolated coronary artery bypass graft surgery (CABG) were enrolled. Their datasets were assigned randomly to training (70%) or a testing set (30%). The primary outcome was major bleeding defined as the universal definition of perioperative bleeding (UDPB) classes 3–4. We constructed a reference logistic regression (LR) model using known predictors. We also developed several modern ML algorithms. In the test set, we compared the area under the receiver operating characteristic curves (AUCs) of these ML algorithms with the reference LR model results, and the TRUST and WILL-BLEED risk score. Calibration analysis was undertaken using the calibration belt method.ResultsThe prevalence of postoperative major bleeding was 7.1% (74/1,045). For major bleeds, the conditional inference random forest (CIRF) model showed the highest AUC [0.831 (0.732–0.930)], and the stochastic gradient boosting (SGBT) and random forest models demonstrated the next best results [0.820 (0.742–0.899) and 0.810 (0.719–0.902)]. The AUCs of all ML models were higher than [0.629 (0.517–0.641) and 0.557 (0.449–0.665)], as achieved by TRUST and WILL-BLEED, respectively.ConclusionML methods successfully predicted major bleeding after cardiac surgery, with greater performance compared with previous scoring models. Modern ML models may enhance the identification of high-risk major bleeding subpopulations.
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Affiliation(s)
- Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaojie Liu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lijuan Wang
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Yu
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yao Ding
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingcan Wang
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hushan Ao
- Department of Anesthesiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Hushan Ao,
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Danker W, Aggarwal J, Kelkar SS, Marston XL, Gao X, Johnston SS. Real-World Clinical and Economic Outcomes Associated with Surgiflo ® vs Floseal in Cardiovascular Surgeries in the US. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:129-138. [PMID: 35299991 PMCID: PMC8922341 DOI: 10.2147/ceor.s338672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background Topical hemostatic agents are an option for controlling bleeding during cardiovascular surgery. Previous studies comparing topical hemostatic agents in cardiovascular surgery predate the 2012 reformulation of Surgiflo®, which had been re-engineered to increase paste viscosity and thus be more adherent to the bleeding surface. Objective To compare clinical and economic outcomes in patients receiving the current formulation of Surgiflo vs Floseal during cardiovascular surgeries. Methodology A retrospective analysis was conducted using the Premier Healthcare Database. Eligible patients had an inpatient cardiovascular surgery between 1/1/2013 and 6/1/2018, were ≥18 years old and received the current formulation of Surgiflo or Floseal during surgery. Propensity score matching was performed, with exact matching on the surgery year and surgery type (aortic, coronary artery bypass grafting, valve, or other). Descriptive analysis and generalized estimating equations models compared outcomes between the Surgiflo and Floseal groups. Results The matched sample included 5768 patients in each group (mean age: 66.5 years; 66.3% male). In the matched sample, rates of any documented bleeding event were similar in Surgiflo and Floseal groups (6.9% vs 7.2%; P = 0.576). Differences in transfusion rates between patients receiving Surgiflo vs Floseal varied by operational definition and timing of measurement but did not differ by >2 percentage points. Compared to Floseal, patients who received Surgiflo experienced longer surgery duration (306.0 vs 299.4 minutes), lower hospitalization cost ($44,146 vs $46,812), and lower odds of readmission at 30, 60, and 90 days post-discharge (all P < 0.05). Inpatient mortality and LOS were comparable between Surgiflo and Floseal (all P > 0.05). Conclusion In this large study of real-world clinical and economic outcomes after cardiovascular surgery involving the current formulation of Surgiflo vs Floseal, Surgiflo was associated with mostly similar clinical outcomes as compared with Floseal. Differences in selected economic/resource use outcomes were also observed, for which root-cause analysis in future research would be informative.
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Affiliation(s)
| | | | | | | | - Xin Gao
- OPEN Health, Bethesda, MD, USA
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5
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Nuttall GA, Smith MM, Smith BB, Christensen JM, Santrach PJ, Schaff HV. A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients. Ann Thorac Cardiovasc Surg 2021; 28:204-213. [PMID: 34937821 PMCID: PMC9209891 DOI: 10.5761/atcs.oa.21-00222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy. Materials and Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements. Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups. Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paula J Santrach
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Mazur P, Litwinowicz R, Tchantchaleishvili V, Natorska J, Ząbczyk M, Bochenek M, Przybylski R, Iwaniec T, Kȩdziora A, Filip G, Kapelak B. Left Internal Mammary Artery Skeletonization Reduces Bleeding—A Randomized Controlled Trial. Ann Thorac Surg 2021; 112:794-801. [DOI: 10.1016/j.athoracsur.2020.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
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7
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Moraes A, Giordani JN, Borges CT, Mariani PE, Costa LMD, Bridi LH, Santos ATLD, Kalil R. Transfusion of Blood Products in the Postoperative of Cardiac Surgery. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20190192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Rubino AS, Nicolini F, Tauriainen T, Demal T, De Feo M, Onorati F, Faggian G, Bancone C, Perrotti A, Chocron S, Dalén M, Santarpino G, Fischlein T, Maselli D, Musumeci F, Santini F, Salsano A, Zanobini M, Saccocci M, Bounader K, Gatti G, Ruggieri VG, Mignosa C, Juvonen T, Mariscalco G, Biancari F. Failure to achieve a satisfactory cardiac outcome after isolated coronary surgery in low-risk patients. Interact Cardiovasc Thorac Surg 2021; 31:9-15. [PMID: 32442254 DOI: 10.1093/icvts/ivaa062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/06/2020] [Accepted: 03/11/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES This study aims to investigate the incidence and determinants of major early adverse events in low-risk patients undergoing isolated coronary artery bypass grafting (CABG). METHODS The multicentre E-CABG registry included 7352 consecutive patients who underwent isolated CABG from January 2015 to December 2016. Patients with an European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of <2% and without any major comorbidity were the subjects of the present analysis. RESULTS Out of 2397 low-risk patients, 11 (0.46%) died during the index hospitalization or within 30 days from surgery. Five deaths were cardiac related, 4 of which were secondary to technical failures. We estimated that 8 out of 11 deaths were potentially preventable. Logistic regression model identified porcelain aorta [odds ratio (OR) 34.3, 95% confidence interval (CI) 1.3-346.3] and E-CABG bleeding grades 2-3 (OR 30.2, 95% CI 8.3-112.9) as independent predictors of hospital death. CONCLUSIONS Mortality and major complications, although infrequently, do occur even in low-risk patients undergoing CABG. Identification of modifiable causes of postoperative adverse events may be useful to develop preventative strategies to improve the quality of care of patients undergoing cardiac surgery. CLINICAL TRIAL REGISTRATION NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083).
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Affiliation(s)
- Antonino S Rubino
- Division of Cardiac Surgery, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Tuomas Tauriainen
- Department of Surgery, Oulu University Hospital and Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland
| | - Till Demal
- Hamburg University Heart Center, Hamburg, Germany
| | - Marisa De Feo
- Division of Cardiac Surgery, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Ciro Bancone
- Division of Cardiac Surgery, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Santarpino
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany.,Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care & Research, Lecce, Italy
| | - Theodor Fischlein
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Francesco Musumeci
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Giuseppe Gatti
- Cardio-Thoracic and Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Vito G Ruggieri
- Division of Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France
| | | | - Tatu Juvonen
- Department of Surgery, Oulu University Hospital and Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland.,Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital and Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland.,Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Chiorino CDRN, Santos VB, Lopes JDL, Lopes CT. Predictors of Hospital Readmission within 30 Days after Coronary Artery Bypass Grafting: Data Analysis of 2,272 Brazilian Patients. Braz J Cardiovasc Surg 2020; 35:884-890. [PMID: 33306313 PMCID: PMC7731841 DOI: 10.21470/1678-9741-2020-0266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction In order to reduce readmission rates after coronary artery bypass grafting (CABG), its predictors should be known in different contexts. The objective of this study was to identify predictive factors of hospital readmission within 30 days after CABG in a Brazilian center. Methods A secondary analysis of an electronic database of patients submitted to isolated CABG was performed. The relationship between readmission within 30 days and demographic, anthropometric, clinical, and surgery-related characteristics was investigated by univariate analyses. Predictors were identified by multiple logistic regression. Results Data from 2,272 patients were included, with an incidence of readmission of 8.6%. The predictors of readmission were brown skin color (Beta=1.613; 95% confidence interval [CI] 1.047-2.458; P=0.030), African-American ethnicity (Beta=0.136; 95% CI 0.019-0.988; P=0.049), chronic kidney disease (Beta=2.214; 95% CI 1.269-3.865; P=0.005), postoperative use of blood products (Beta=1.515; 95% CI 1.101-2.086; P=0.011), chronic obstructive pulmonary disease (Beta=2.095; 95% CI 1.284-3.419; P=0.003), and use of acetylsalicylic acid (Beta=1.418; 95% CI 1.000-2.011; P=0.05). Preoperative antibiotic prophylaxis (Beta=0.742; 95% CI 0.5471.007; P=0.055) was marginally significant. Conclusion The predictors identified may support a closer postoperative follow-up and individualized planning for a safe discharge.
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Affiliation(s)
- Camilla do Rosário Nicolino Chiorino
- Educação Corporativa da Associação Beneficência Portuguesa de São Paulo, São Paulo, Brazil.,Programa de Pós-Graduação em Enfermagem, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vinicius Batista Santos
- Departamento de Enfermagem Clínica e Cirúrgica, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Juliana de Lima Lopes
- Departamento de Enfermagem Clínica e Cirúrgica, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Camila Takao Lopes
- Programa de Pós-Graduação em Enfermagem, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil.,Departamento de Enfermagem Clínica e Cirúrgica, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
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10
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D'Alessandro S, Guarracino F, Nicolini F, Formica F. Commentary: Shall we wait for two days more? Can we take this risk? J Thorac Cardiovasc Surg 2020; 163:1056-1057. [PMID: 32471698 DOI: 10.1016/j.jtcvs.2020.04.076] [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: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stefano D'Alessandro
- Cardiac Surgery Unit, Cardiac-Thoracic-Vascular Department, San Gerardo Hospital, Monza, Italy
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Cardiothoracic and Vascular Anaesthesia and Intensive Care, University Hospital, Pisa, Italy
| | - Francesco Nicolini
- Cardiac Surgery Unit, Department of Medicine and Surgery, Parma General Hospital, University of Parma, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, Department of Medicine and Surgery, Parma General Hospital, University of Parma, Italy.
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11
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Salsano A, Dominici C, Nenna A, Olivieri GM, Miette A, Barbato R, Sportelli E, Natali R, Maestri F, Chello M, Mariscalco G, Santini F. Predictive scores for major bleeding after coronary artery bypass surgery in low operative risk patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:234-242. [PMID: 31937080 DOI: 10.23736/s0021-9509.20.11048-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiac surgery is associated with perioperative bleeding and carries high risk of allogeneic blood transfusion. Recently new scores for prediction of severe bleeding have been developed. This study aims to compare the WILL-BLEED, CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting major bleeding after CABG in patients with low estimated operative risk. METHODS A multicenter observational study included 1391 patients who underwent isolated CABG from July 2015 to January 2018. We tested the hypothesis that the WILL-BLEED score, specifically designed for CABG, would perform at least as well as the CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting postoperative major bleeding in low operative risk patients. The primary endpoint was the performance of known bleeding risk scores after CABG. The secondary endpoint was the evaluation of in-hospital mortality. RESULTS Mean age was 68.2±9.4 years and median Euroscore II value was 1.69% (IQR 1.15-2.81%). Mean blood losses in the first 12 postoperative hours was 339.75 mL. Seventy-three (5.2%) subjects underwent administration of blood products. The rate of severe-massive bleeding according to UDPB grades 3-4 was 1.5%. WILL-BLEED, TRUST, TRACK and ACTION scores were significantly associated with severe postoperative bleeding. WILL-BLEED presented the best c-index (AUC: 0.658; 95% CI: 0.600,0.716). Reclassification analysis showed a worsening in sensitivity and significant negative reclassification of CRUSADE, PAPWORTH, TRACK and ACTION scores when compared with WILL-BEED. The combination of WILL-BLEED and TRUST scores improved the prediction ability (AUC: 0.673; 95% CI: 0.615-0.732). Overall in-hospital mortality was 1.65%. Early mortality in patients with severe versus no-severe bleeding was found to be 11.8% vs. 1.0% Severe bleeding (OR: 13.26; P value<0.001) was found to be significantly associated with early mortality. CONCLUSIONS Severe bleeding after CABG is a harmful event associated with adverse outcomes. WILL-BLEED Score has the better performance in predicting severe-massive bleeding after CABG. The TRUST Score, although suboptimal, represents a valuable alternative in this setting.
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Affiliation(s)
- Antonio Salsano
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy -
| | - Carmelo Dominici
- Division of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Antonio Nenna
- Division of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Guido M Olivieri
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
| | - Ambra Miette
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
| | - Raffaele Barbato
- Division of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Elena Sportelli
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
| | - Roberto Natali
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
| | - Francesco Maestri
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
| | - Massimo Chello
- Division of Cardiovascular Surgery, Campus Bio-Medico University, Rome, Italy
| | - Giovanni Mariscalco
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy.,Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
| | - Francesco Santini
- Division of Cardiac Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy
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12
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Xi Z, Gao Y, Yan Z, Zhou YJ, Liu W. The Prognostic Significance of Different Bleeding Classifications in off-pump coronary artery bypass grafting. BMC Cardiovasc Disord 2020; 20:3. [PMID: 31924163 PMCID: PMC6954587 DOI: 10.1186/s12872-019-01315-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 12/19/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Perioperative bleeding during cardiac surgery are known to make patients susceptible to adverse outcomes and several bleeding classifications have been developed to stratify the severity of bleeding events. Further validation of different classifications was needed. The aim of present study was to validate and explore the prognostic value of different bleeding classifications in patients undergoing off-pump coronary artery bypass grafting (OPCAB). METHODS Data on baseline and operative characteristics of 3988 patients who underwent OPCAB in Beijing Anzhen Hospital from February 2008 to December 2014 were available. The primary endpoint was a composite of in-hospital death and nonfatal postoperative myocardial infarction (MI). The secondary endpoint was postoperative acute kidney injury (AKI). We explored the association of major bleeding defined by the European registry of Coronary Artery Bypass Grafting (E-CABG), Universal Definition of Perioperative Bleeding (UDPB), Bleeding Academic Research Consortium (BARC) classification and Study of Platelet Inhibition and Patient Outcomes (PLATO) with primary endpoints by multivariable logistic regression analysis and investigated their significance of adverse event prediction using goodness-of-fit tests of - 2 log likelihood. RESULTS In-hospital mortality was 1.23% (n = 49) and postoperative MI was observed in 4.76% (n = 190) of patients, AKI in 24.69% (n = 985). The incidence of the primary outcome was 5.99% (n = 239). Multivariable logistic regression analysis showed that BARC type 4 (OR = 2.64, 95% CI: 1.66-4.19, P < 0.001), UDPB class 4 (OR = 3.52, 95% CI: 2.05-6.02, P < 0.001) and E-CABG class 2-3 (class 2: OR = 2.24, 95% CI: 1.36-3.70, P = 0.001; class 3: OR = 12.65, 95% CI: 2.74-18.43, P = 0.002) bleeding but not PLATO bleeding were associated with an increased risk of in-hospital death and postoperative MI. Major bleeding defined by all the four classifications mentioned above was an independent risk factor of AKI after surgery. Inclusion of major bleeding defined by these four classifications improved the predictive performance of the multivariable model with baseline characteristics. CONCLUSIONS Bleeding assessed by BARC, E-CABG and UDPB classifications were significantly associated with poorer immediate outcomes. These classifications seemed to be valuable tool in the assessment of prognostic effect of perioperative bleeding.
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Affiliation(s)
- Ziwei Xi
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029 China
| | - Yanan Gao
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029 China
| | - Zhenxian Yan
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029 China
| | - Yu-Jie Zhou
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029 China
| | - Wei Liu
- Department of Cardiology, Beijing Anzhen hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029 China
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13
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Mazur P, Litwinowicz R, Krzych Ł, Bochenek M, Wasilewski G, Hymczak H, Bartuś K, Filip G, Przybylski R, Kapelak B. Absence of perioperative excessive bleeding in on-pump coronary artery bypass grafting cases performed by residents. Interact Cardiovasc Thorac Surg 2019; 29:836-843. [PMID: 31435666 DOI: 10.1093/icvts/ivz195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES On-pump coronary artery bypass grafting (CABG) is associated with elevated bleeding risk. Our aim was to evaluate the role of surgical experience in postoperative blood loss. METHODS A propensity score-matched analysis was employed to compare on-pump CABG patients operated on by residents and specialists. End points included drainage volume and bleeding severity, as assessed by the Universal Definition of Perioperative Bleeding in cardiac surgery and E-CABG scale. RESULTS A total of 212 matched pairs (c-statistics 0.693) were selected from patients operated on by residents (n = 294) and specialists (n = 4394) between October 2012 and May 2018. Patients did not differ in bleeding risk. There were no statistically significant differences in postoperative 6-, 12- and 24-h drainages between subjects operated on by residents and specialists, and there was no between-group difference in rethoracotomy or transfusion rate. There were no differences in Universal Definition of Perioperative Bleeding or E-CABG grades. In June 2018, after a median follow-up of 2.8 years (range 0.1-5.7 years), the overall survival was 94%, with no differences between the patients operated on by residents (95%) and specialists (92%) (P = 0.27). CONCLUSIONS Patients undergoing on-pump CABG, when operated on by a resident, are not exposed to an elevated bleeding risk, as compared with patients operated on by experienced surgeons.
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Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Łukasz Krzych
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Bochenek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Wasilewski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Hubert Hymczak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Filip
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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14
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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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15
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Beverly A, Ong G, Wilkinson KL, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in adults undergoing cardiac surgery: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anair Beverly
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Giok Ong
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Kirstin L Wilkinson
- Southampton University NHS Hospital; Paediatric and Adult Cardiothoracic Anaesthesia; Tremona Road Southampton UK SO16 6YD
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Nicky J Welton
- University of Bristol; Population Health Sciences, Bristol Medical School; Bristol UK
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
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16
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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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17
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Roman M, Biancari F, Ahmed AB, Agarwal S, Hadjinikolaou L, Al-Sarraf A, Tsang G, Oo AY, Field M, Santini F, Mariscalco G. Prothrombin Complex Concentrate in Cardiac Surgery: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2018; 107:1275-1283. [PMID: 30458156 DOI: 10.1016/j.athoracsur.2018.10.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/28/2018] [Accepted: 10/01/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prothrombin complex concentrate (PCC) has recently emerged as an effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. This systematic review and meta-analysis evaluated the safety and efficacy of PCC administration as first-line treatment for coagulopathy after adult cardiac surgery. METHODS PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared with patients receiving FFP. RESULTS A total of 861 adult patients from four studies were retrieved. No randomized studies were identified. Pooled odds ratios (ORs) showed that the PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR, 2.22; 95% confidence interval [CI], 1.45 to 3.40) and units of RBC received (OR, 1.34; 95% CI, 0.78 to 1.90). No differences were observed between the groups for reexploration for bleeding (OR, 1.09; 95% CI, 0.66 to 1.82), chest drain output at 24 hours (OR, 66.36; 95% CI, -82.40 to 216.11), hospital mortality (OR, 0.94; 95% CI, 0.59 to 1.49), stroke (OR, 0.80; 95% CI, 0.41 to 1.56), and occurrence of acute kidney injury (OR, 0.80; 95% CI, 0.58 to 1.12). A trend toward increased risk of renal replacement therapy was observed in the PCC group (OR, 0.41; 95% CI, 0.16 to 1.02). CONCLUSIONS In patients with significant bleeding after cardiac surgery, PCC administration seems to be more effective than FFP in reducing perioperative blood transfusions. No additional risks of thromboembolic events or other adverse reactions were observed. Randomized controlled trials are needed to establish the safety of PCC in cardiac surgery definitively.
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Affiliation(s)
- Marius Roman
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland
| | - Aamer B Ahmed
- Department of Anesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Seema Agarwal
- Department of Anesthesia, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Leon Hadjinikolaou
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ali Al-Sarraf
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Geoff Tsang
- Cardiac Surgery Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Aung Y Oo
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Francesco Santini
- Department of Integrated Surgical and Diagnostic Sciences, Division of Cardiac Surgery, University of Genoa, Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom; Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
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18
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Hill A, Wendt S, Benstoem C, Neubauer C, Meybohm P, Langlois P, Adhikari NK, Heyland DK, Stoppe C. Vitamin C to Improve Organ Dysfunction in Cardiac Surgery Patients-Review and Pragmatic Approach. Nutrients 2018; 10:nu10080974. [PMID: 30060468 PMCID: PMC6115862 DOI: 10.3390/nu10080974] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/22/2018] [Accepted: 07/25/2018] [Indexed: 12/15/2022] Open
Abstract
The pleiotropic biochemical and antioxidant functions of vitamin C have sparked recent interest in its application in intensive care. Vitamin C protects important organ systems (cardiovascular, neurologic and renal systems) during inflammation and oxidative stress. It also influences coagulation and inflammation; its application might prevent organ damage. The current evidence of vitamin C's effect on pathophysiological reactions during various acute stress events (such as sepsis, shock, trauma, burn and ischemia-reperfusion injury) questions whether the application of vitamin C might be especially beneficial for cardiac surgery patients who are routinely exposed to ischemia/reperfusion and subsequent inflammation, systematically affecting different organ systems. This review covers current knowledge about the role of vitamin C in cardiac surgery patients with focus on its influence on organ dysfunctions. The relationships between vitamin C and clinical health outcomes are reviewed with special emphasis on its application in cardiac surgery. Additionally, this review pragmatically discusses evidence on the administration of vitamin C in every day clinical practice, tackling the issues of safety, monitoring, dosage, and appropriate application strategy.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- Department of Anesthesiology, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
| | - Sebastian Wendt
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital RWTH, D-52074 Aachen, Germany.
| | - Carina Benstoem
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
| | - Christina Neubauer
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
| | - Patrick Meybohm
- Department of Anesthesiology and Intensive Care, University Hospital Frankfurt, D-60590 Frankfurt, Germany.
| | - Pascal Langlois
- Department of Anesthesiology and Reanimation, Faculty of Médecine and Health Sciences, Sherbrooke University Hospital, Sherbrooke, Québec, QC J1H 5N4, Canada.
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care Medicine, University of Toronto; Toronto, ON M4N 3M5, Canada.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON K7L 2V7, Canada.
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany.
- 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.
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19
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Liu W, Xi Z, Gu C, Dong R, AlHelal J, Yan Z. Impact of major bleeding on the risk of acute kidney injury in patients undergoing off-pump coronary artery bypass grafting. J Thorac Dis 2018; 10:3381-3389. [PMID: 30069333 DOI: 10.21037/jtd.2018.05.98] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Patients with perioperative bleeding during cardiac surgery are susceptible to acute kidney injury (AKI) which is proposed to be associated with short-term and long-term risk of adverse events. The relationship between perioperative bleeding in off-pump coronary artery bypass grafting (OPCAB) and AKI remains unknown. The purpose of this study is to evaluate the impact of perioperative bleeding on the risk of postoperative AKI in patient undergoing OPCAB. Methods Perioperative major bleeding was defined by the universal definition of perioperative bleeding (UDPB) class 3 to 4. The primary endpoint was postoperative AKI which was diagnosed using criteria of stage 1 of AKI proposed by Acute Kidney Injury Network (AKIN). The secondary endpoints included in-hospital mortality and the incidence of postoperative myocardial infarction (MI). Baseline characteristics were compared between patients with and without major bleeding. Multivariable logistic regression analysis was performed to identify potential predictive factors for AKI after OPCAB. Results A total of 4,030 ACS (acute coronary syndrome) patients who underwent OPCAB were included in this study. Major bleeding rate was 9.8% (n =394). AKI was found in 995 (24.7%) patients. Multivariable regression analysis showed that perioperative major bleeding conferred a significantly higher risk of AKI after OPCAB with an odds ratio of 1.67 (95% confidence interval 1.32-2.10, P<0.001). When a decrease in hemoglobin, transfusion and chest tube output were included in the same logistic model separately to replace major bleeding, transfusion was the most strongly risk factor associated with AKI after surgery (OR =2.08, 95% CI: 1.38-3.16, P<0.001). Conclusions Perioperative bleeding is associated with a higher risk of postoperative AKI in ACS patients who underwent OPCAB. Moreover, blood and blood products transfusion most correlated with AKI after surgery. Prevention of severe bleeding and reducing blood transfusion requirement may improve the outcomes of OPCAB.
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Affiliation(s)
- Wei Liu
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Ziwei Xi
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Chengxiong Gu
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Ran Dong
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jumana AlHelal
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Zhenxian Yan
- Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Aneman A, Brechot N, Brodie D, Colreavy F, Fraser J, Gomersall C, McCanny P, Moller-Sorensen PH, Takala J, Valchanov K, Vallely M. Advances in critical care management of patients undergoing cardiac surgery. Intensive Care Med 2018; 44:799-810. [DOI: 10.1007/s00134-018-5182-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/12/2018] [Indexed: 12/23/2022]
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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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Kinnunen EM, Zanobini M, Onorati F, Brascia D, Mariscalco G, Franzese I, Ruggieri VG, Bounader K, Perrotti A, Musumeci F, Santarpino G, Maselli D, Nardella S, Gulbins H, Gherli R, Rubino AS, Mignosa C, De Feo M, Gatti G, Santini F, Salsano A, Dalén M, Saccocci M, Reichart D, Faggian G, Gherli T, Nicolini F, Biancari F. The impact of minor blood transfusion on the outcome after coronary artery bypass grafting. J Crit Care 2017; 40:207-212. [PMID: 28445858 DOI: 10.1016/j.jcrc.2017.04.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/28/2017] [Accepted: 04/14/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). METHODS Sixteen cardiac surgical centers contributed to the prospective European CABG registry (E-CABG). 1014 patients receiving 1-2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs. RESULTS In 827 propensity score matched pairs, transfusion of 1-2 RBC units did not affect the risk of in-hospital/30-day death (p=0.523) or stroke (p=0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p=0.008), sternal wound infection (p=0.001), postoperative use of antibiotics (p=0.001), prolonged use of inotropes (p<0.0001), use of intra-aortic balloon pump (p=0.012), length of intensive care unit stay (p<0.0001) and length of in-hospital stay (p<0.0001). Matched paired analysis excluding pre- and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in-hospital/30-day death. CONCLUSION Minor perioperative bleeding and subsequent transfusion of 1-2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low-volume RBC transfusion may improve the outcome after CABG.
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Affiliation(s)
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Debora Brascia
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Ilaria Franzese
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Francesco Musumeci
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Saverio Nardella
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | | | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | | | - Marisa De Feo
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | | | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | | | - Giuseppe Faggian
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Tiziano Gherli
- Division of Cardiac Surgery, University of Parma, Parma, Italy
| | | | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
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