Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery

Biomarkers of inflammation and coagulation after minimally invasive mitral valve surgery: a prospective comparison to conventional surgery

OBJECTIVES

Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy.

DESIGN

A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored.

RESULTS

The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115-146] vs 79 min [65-112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23-69] vs 61[41-139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400-1040], p = 0.04).

CONCLUSIONS

Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.

Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention

Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.

Investigation of von Willebrand factor multimer abnormalities before and after aortic valve replacement using the Hydragel-5 assay

BACKGROUND

Severe aortic stenosis (sAS) is associated with acquired von Willebrand syndrome (AVWS) by loss of high-molecular-weight multimers (HMWM) of von Willebrand factor (VWF), potentially resulting in perioperative bleeding. Analysis of VWF multimers remains challenging. Recently, the new, rapid Hydragel 5 assay has been developed, using electrophoretic protein separation for dividing VWF-multimers into low (LMWM), intermediate (IMWM), and HMWM, the hemostatically active part of VWF. Here, we evaluated its impact on predicting blood loss in presence of AVWS after surgical aortic valve replacement (SAVR).

METHODS

We prospectively examined 52 patients (age: 68 ± 7 years; 54 % male) admitted to SAVR. They were divided in two groups (A: normal VWF, n = 28; B: abnormal VWF, n = 24, defined as VWF-activity/antigen (VWF:Ac/Ag)-ratio < 0.7 and/or HMWM loss). Blood samples and echocardiographic data were collected before, seven days and three months after SAVR. Blood loss and transfusions were recorded.

RESULTS

Baseline characteristics and clinical data were similar in both groups. HMWM loss was present in 38.5 % of all patients. HMWM, the VWF:Ac/Ag- and HMWM/(IMWM+LMWM)-ratios were significantly decreased preoperatively in group B but normalized after SAVR. Bleeding, re-thoracotomy and transfusion rates were comparable. HMWM loss was inversely correlated with the peak aortic gradient (Pmax) and positively with the aortic valve area (AVA), while HMWM/(IMWM+LMWM)-ratio negatively correlated with the mean aortic gradient (Pmean).

CONCLUSION

HMWM and HMWM/(IMWM+LMWM)-ratio inversely correlate with severity of AS and normalize after SAVR. The Hydragel-5 assay's might be valuable for routine diagnostics to assess bleeding risk and postoperative normalization of AS and VWF abnormalities in SAVR patients.

The association of perioperative blood transfusion with survival outcomes after major cancer surgery: a population-based cohort study in South Korea

PURPOSE

The correlation between perioperative blood transfusions and the prognosis after major cancer surgery remains controversial. We investigated the association between perioperative blood transfusion and survival outcomes following major cancer surgeries and analyzed trends in perioperative blood transfusions.

METHODS

Data for this population-based cohort study were obtained from the National Health Insurance Service of South Korea. Adult patients who underwent major cancer surgery between January 1, 2016, and December 31, 2020, were included. The primary endpoint was 90-day mortality.

RESULTS

The final analysis included 253,016 patients, of which 55,094 (21.8%) received perioperative blood transfusions. In the multivariable logistic regression model, select factors, including neoadjuvant/adjuvant chemotherapy, an increased preoperative Charlson Comorbidity Index, moderate or severe liver disease, liver cancer surgery, and small bowel cancer surgery, were associated with an increased likelihood of blood transfusion. In the multivariable Cox regression model, patients who received blood transfusion had a significantly higher risk of 90-day mortality (hazard ratio: 5.68; 95% confidence interval: 5.37, 6.00; P < 0.001) than those who did not.

CONCLUSION

We identified potential risk factors for perioperative blood transfusions. Blood transfusion is associated with an increased 90-day mortality risk after major cancer surgery.

Minimal Learning Curve for Minimally Invasive Aortic Valve Replacement

BACKGROUND

 Minimally invasive aortic valve replacement (MiAVR) is an established technique for surgical aortic valve replacement (AVR). Although MiAVR was first described in 1993 and has shown good results compared with full sternotomy AVR (FSAVR) only a minority of patients undergo MiAVR. We recently started using MiAVR via an upper hemisternotomy. We aimed to examine the early results of our initial experience with this technique.

METHODS

 We compared 55 MiAVR patients with a historical cohort of 142 isolated FSAVR patients (December 2016-December 2022). The primary outcome was in-hospital mortality. Secondary outcomes included cardiopulmonary bypass (CPB) and cross-clamp times, blood product intake, in-hospital morbidity, and length of intensive care unit and hospital stay.

RESULTS

 There was no significant difference in preoperative characteristics, including age, laboratory values, and comorbidities. There was no significant difference between the groups regarding in-hospital mortality (FSAVR 3.52 vs. MiAVR 1.82%). There was no significant difference in CPB time (FSAVR 103.5 [interquartile range: 82-119.5] vs. MiAVR 107 min [92.5-120]), aortic cross-clamp time (FSAVR 81 [66-92] vs. MiAVR 90 min [73-99]), and valve size (FSAVR 23 [21-25] vs. MiAVR 23 [21-25]). The incidence of intraoperative blood products transfusion was significantly lower in the MiAVR group (10.91%) compared with the FSAVR group (25.35%, p = 0.03).

CONCLUSION

 Our findings further establish the possibility of reducing invasiveness of AVR without compromising patient safety and clinical outcomes. This is true even in the learning curve period and without requiring any significant change in the operative technique and dedicated equipment.

Hemostatic effects of tranexamic acid in cardiac surgical patients with antiplatelet therapy: a systematic review and meta-analysis

BACKGROUND

The purpose of the current study was to assess the efficacy of tranexamic acid (TXA) on reducing bleeding in cardiac surgical patients with preoperative antiplatelet therapy (APT).

METHODS

Five electronic databases were searched systematically for randomized-controlled trials (RCTs) assessing the impact of intravenous TXA on post-operative bleeding on cardiac surgical patients with preoperative APT until May 2024. Primary outcome of interest was post-operative blood loss. Secondary outcomes of interest included the incidence of reoperation due to post-operative bleeding, post-operative transfusion requirements of red blood cells (RBC), fresh-frozen plasma (FFP), and platelet concentrates. Mean difference (MD) with 95% confidence interval (CI) or odds ratios (OR) with 95% CI was employed to analyze the data. Subgroup and meta-regression analyses were performed to assess the possible influence of TXA administration on reducing bleeding and transfusion requirements.

RESULTS

A total of 12 RCTs with 3018 adult cardiac surgical patients (TXA group, 1510 patients; Control group, 1508 patients) were included. The current study demonstrated that TXA significantly reduced post-operative blood loss (MD =  - 0.38 L, 95% CI: - 0.73 to - 0.03, P = 0.03; MD =  - 0.26 L, 95% CI: - 0.28 to - 0.24, P < 0.00001; MD =  - 0.37 L, 95% CI: - 0.63 to - 0.10, P = 0.007) in patients receiving dual antiplatelet therapy (DAPT), aspirin, or clopidogrel, respectively. Patients in TXA group had significantly lower incidence of reoperation for bleeding as compared to those in Control group. The post-operative transfusion of RBC and FFP requirements was significantly lower in TXA group than Control group. Subgroup analyses showed that studies with DAPT discontinued on the day of surgery significantly increased the risk of post-operative blood loss [(MD: - 1.23 L; 95% CI: - 1.42 to - 1.04) vs. (MD: - 0.16 L; 95% CI: - 0.27 to - 0.05); P < 0.00001 for subgroup difference] and RBC transfusion [(MD: - 3.90 units; 95% CI: - 4.75 to - 3.05) vs. (MD: - 1.03 units; 95% CI: - 1.96 to - 0.10); P < 0.00001 for subgroup difference] than those with DAPT discontinued less than 5-7 days preoperatively.

CONCLUSIONS

This meta-analysis demonstrated that TXA significantly reduced post-operative blood loss and transfusion requirements for cardiac surgical patients with preoperative APT. These potential clinical benefits may be greater in patients with aspirin and clopidogrel continued closer to the day of surgery.

TRIAL REGISTRATION NUMBER

CRD42022309427.

The effect of incremental increases in the number of packed red blood cell units transfused on perioperative outcomes in open abdominal aortic aneurysm repair

INTRODUCTION

Despite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications.

METHODS

Patients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications.

RESULTS

Of 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications.

DISCUSSION

There appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.

A precise blood transfusion evaluation model for aortic surgery: a single-center retrospective study

Cardiac aortic surgery is an extremely complicated procedure that often requires large volume blood transfusions during the operation. Currently, it is not possible to accurately estimate the intraoperative blood transfusion volume before surgery. Therefore, in this study, to determine the clinically precise usage of blood for intraoperative blood transfusions during aortic surgery, we established a predictive model based on machine learning algorithms. We performed a retrospective analysis on 4,285 patients who received aortic surgery in Beijing Anzhen Hospital between January 2018 and September 2022. Ultimately, 3,654 patients were included in the study, including 2,557 in the training set and 1,097 in the testing set. By utilizing 13 current mainstream models and a large-scale cardiac aortic surgery dataset, we built a novel machine learning model for accurately predicting intraoperative red blood cell transfusion volume. Based on the transfusion-related risk factors that the model identified, we also established the relevant variables that affected the results. The results revealed that decision tree models were the most suitable for predicting the blood transfusion volume during aortic surgery. In particular, the mean absolute error for the best-performing extremely randomized forest model was 1.17 U, while the R2 value was 0.50. Further exploration into intraoperative blood transfusion during aortic surgery identified erythrocytes, estimated operation duration, body weight, sex, red blood cell count, and D-dimer as the six most significant risk factors. These factors were subsequently analyzed for their influence on intraoperative blood transfusion volume in relevant patients, as well as the protective threshold for prediction. The novel intraoperative blood transfusion prediction model for cardiac aorta surgery in this study effectively assists clinicians in accurately calculating blood transfusion volumes and achieving effective utilization of blood resources. Furthermore, we utilize interpretability technology to reveal the influence of critical risk factors on intraoperative blood transfusion volume, which provides an important reference for physicians to provide timely and effective interventions. It also enables personalized and precise intraoperative blood usage.

Nonanemic Iron Deficiency in Cardiac Surgery: A Retrospective Observational Study

OBJECTIVES

Anemia and iron deficiency in patients having cardiac surgery increases their perioperative risk. Nonanemic iron deficiency (NAID) in this group is less well-described. We aimed to investigate the incidence and outcomes of patients with NAID undergoing cardiac surgery.

DESIGN

Retrospective observational study.

SETTING

A single, tertiary referral center.

PARTICIPANTS

Adult patients who were preassessed and underwent cardiac surgery during the study period had data collected. We enrolled 537 patients enrolled and divided them into 4 groups according to hemoglobin and ferritin: NAID, nonanemic iron replete, iron-deficiency anemia (IDA), and non-iron-deficiency anemia.

INTERVENTIONS

This study was not interventional, but assessed the impact of anemia and iron deficiency on patient outcomes.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the incidence of NAID. Secondary outcomes included the number of patients who became anemic awaiting surgery, allogeneic transfusion burden, length of stay, postoperative complications, and death. 179 of 537 patients (33.3%) had NAID. Seventeen patients (9.5%) became anemic in the NAID group compared with 7 (3.3%) in the nonanemic iron replete group while awaiting for surgery (p = 0.02). Patients with NAID were more likely to receive allogeneic transfusions (33% vs 23%; p = 0.04) and had poorer recovery of hemoglobin at follow-up (13.2 ± 1.46 g/dL vs 13.9 ± 1.46 g/dL; p < 0.001).

CONCLUSIONS

NAID is common and can lead to progression to anemia and increased transfusion. Iron replacement should be considered in patients with NAID in the preoperative setting. A prospective interventional trial is required to demonstrate the benefit of being iron replete.

Comparison of Two Surgical Approaches for Coronary Artery Bypass of Left Anterior Descending Artery

Background/Objectives: The minimally invasive approach through left mini-thoracotomy is a promising alternative to the median sternotomy for coronary artery bypass. The aim of this study was to compare the short-term outcomes of patients undergoing minimally invasive coronary artery bypass (MIDCAB) with off-pump coronary artery bypass through sternotomy (OPCAB) for single-vessel disease. Methods: From January 2017 to February 2023, 377 consecutive patients aged above 18 years undergoing off-pump bypass of the left anterior descending artery (LAD) with left internal thoracic artery underwent OPCAB. Propensity score matching was then applied. Primary endpoints were in-hospital mortality and 30-day mortality. Results: Prior to matching, 30-day mortality occurred in 2 (0.7%) patients in the MIDCAB group vs. 1 (1%) patient in the OPCAP group (p = 1). Transfusion of red blood cells (RBC) was required in 9.4% and 29% of patients within the MIDCAB and the OPCAB groups, respectively (p < 0.001). Median intensive care stay (ICU) was 1 [1-2] day in the MIDCAB group, vs. 2 [1-3] in the OPCAB (p < 0.001). In the matched cohort, 10% of MIDCAB patients received RBCs vs. 27.5% of OPCAB patients (p = 0.006). Median ICU stay was significantly lower in the MIDCAB group, 1 [1-2] vs. 2 [1-3] days. Conclusions: MIDCAB is as safe and effective as OPCAB for single coronary artery bypass of the LAD with the LITA in select patients. It is associated with a decreased ICU stay and lower transfusion rates when compared with OPCAB.

Post-operative infections after cardiothoracic surgery and vascular procedures: a bibliometric and visual analysis of the 100 most-cited articles in the past 2 decades

Aim

To recognize and analyze the 100 most-cited articles on post-operative infections following cardiothoracic surgery and vascular procedures in the past 20 years.

Methods

Articles published on post-operative infections following cardiothoracic surgery and vascular procedures from inception 1986 till 2020 were reviewed and selected by two authors, based on their number of citations using the Scopus database. Their characteristics were recorded, i.e., title, authors, publication date, total no. of citations, citations per year (CPY), country of research, institutional affiliation, journal, research subject, and article type.

Results

The top 100 most influential articles were published between 1968 and 2017, with the peak in 2002. The mean number of total citations was 236.79 (range: 108-1,157). Areas with a medical focus were predominant in the studied research articles on the researched topic. The top-most journals in which these articles were published include Annals of Thoracic Surgery (14), followed by Circulation (8), and the New England Journal of Medicine (8). The number of publications affiliated with an institution were highest in the United States, with the Cleveland Clinic Foundation (6) having the most.

Conclusion

These findings highlight that there is a great potential to conduct research and publish the prevalence, causes, risk factors, pathogenesis and molecular biology of post-cardiac and -vascular surgery infections to prevent their adverse effects. The results can be taken into consideration for policy making to improve post-cardiac-surgery outcomes.

The effectiveness of cell salvage in extracorporeal circulation surgeries in relation to use of health resources after use: A systematic review and meta-analysis

Background

Alternatives to allogeneic blood transfusions are sought for resource management reasons and it is necessary to investigate the efficiency and efficacy on Cell Salvage use. The objective of this study is to analyze the effectiveness of the Cell Salvage system in addressing factors related to healthcare service utilization that may lead to increased healthcare expenditure.

Methods

A systematic review with meta-analysis was conducted through literature search in Medline, CINAHL, Scopus, Web of Science, and Cochrane Library. Inclusion criteria were studies in English/Spanish, without year restriction and Randomized Controlled Trials design, conducted in adults.

Results

Twenty-six studies were included in the systematic review, involving a total of 4781 patients (nexperimental group = 2365; ncontrol group = 2416). Significant differences favored the Cell Salvage system in units of transfused Red Blood Cells, in terms of units (p = 0.04; SMD = -0.42 95 % CI = -0.83 to -0.02) and individuals (p = 0.001; RR = 0.71, 95 % CI = 0.60 to 0.84) transfused. No significant differences were found in ICU (p = 0.93) and hospital stay duration (p = 0.21), number of reoperations (p = 0.68), and number of units and individuals transfused in terms of platelets (p > 0.05).

Conclusions

Cell Salvage use holds high potential for reducing healthcare costs and indirectly contributing to improving blood and blood product reserves within blood banks. Results obtained thus far do not provide definitive evidence regarding the duration of hospital stay, ICU stay, need for reoperation, or the quantity of transfused platelets. Therefore, it is recommended to increase the number of studies to assess the impact on the economic models of the Cell Salvage system.

Management of Anticoagulation and Antifibrinolytics in Catastrophic Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is an autoimmune disorder that presents with hypercoagulability and results in a lab artifact of prolonged PTT. The most severe form is catastrophic antiphospholipid antibody syndrome (CAPS), which manifests as rapidly progressing thromboses in multiple organ systems leading to multi-organ ischemia. The mainstay management CAPS is anticoagulation and systemic corticosteroids. Antifibrinolytic agents have previously been thought to be relatively contraindicated in CAPS due to the pro-thrombotic nature of the disease; the complex coagulation profile of CAPS can make it difficult to assess the risks and benefits of antifibrinolytic therapy. Also, should a patient with CAPS require cardiopulmonary bypass (CPB) for surgery, it poses a unique challenge in providing appropriate anticoagulation in the setting of prolonged ACT. We present a case of a 32-year-old postpartum female with CAPS requiring heart transplant who safely received intraoperative antifibrinolytic therapy and was successfully anticoagulated during CPB after perioperative plasmapheresis.

Analysis of Anemia, Transfusions, and CABG Outcomes in The Society of Thoracic Surgeons National Database

BACKGROUND

This study characterized the association of preoperative anemia and intraoperative red blood cell (RBC) transfusion on outcomes of elective coronary artery bypass grafting (CABG).

METHODS

Data from 53,856 patients who underwent CABG included in The Society of Thoracic Surgeons (STS) Adult Cardiac Database in 2019 were used. The primary outcome was operative mortality. Secondary outcomes were postoperative complications. The association of anemia with outcomes was analyzed with multivariable regression models. The influence of intraoperative RBC transfusion on the effect of preoperative anemia on outcomes was studied using mediation analysis.

RESULTS

Anemia was present in 25% of patients. Anemic patients had a higher STS Predicted Risk of Operative Mortality (1.2% vs 0.7%; P < .001). Anemia was associated with operative mortality (odds ratio [OR], 1.27; 99.5% CI, 1.00-1.61; P = .047), postoperative RBC transfusion (OR, 2.28; 99.5% CI, 2.12-2.44; P < .001), dialysis (OR, 1.58; 99.5% CI, 1.19-2.11; P < .001), and prolonged intensive care unit and hospital length of stay. Intraoperative RBC transfusion largely mediated the effects of anemia on mortality (76%), intensive care unit stay (99%), and hospital stay, but it only partially mediated the association with dialysis (34.9%).

CONCLUSIONS

Preoperative anemia is common in patients who undergo CABG and is associated with increased postoperative risks of mortality, complications, and RBC transfusion. However, most of the effect of anemia on mortality is mediated through intraoperative RBC transfusion.

Perioperative Transfusion and Mortality for Cardiovascular Surgery: A Cohort Study Based on Population in Republic of Korea

Objective:This study aimed to evaluate the rate of transfusion for cardiovascular surgeries between 2010 and 2019 in Republic of Korea and the association between blood transfusion and postoperative mortality. Methods: Data were extracted from the National Health Insurance Service database in Republic of Korea. This study includes adult patients who underwent cardiovascular surgery between 1 January 2010 and 31 December 2019. The endpoints were in-hospital mortality and the 1-year all-cause mortality. Results: The analysis included 62,794 cases, with transfusions used in 88.8% of cases. Multivariable logistic regression revealed that older age, comorbidities, hospital admission through the emergency room, aortic procedures (versus coronary artery bypass grafting), cardiopulmonary bypass, repeat procedures, and supportive therapies during the intensive care (extracorporeal membrane oxygenation and mechanical ventilation) were risk factors for blood transfusion. Female sex was associated with a lower risk of transfusion. Perioperative blood transfusion was associated with a 6.87-fold increased risk of in-hospital mortality (odds ratio [OR]: 6.87, 95% confidence interval [CI]: 3.95, 11.93; p < 0.001) and a 3.20-fold increased risk of 1-year all-cause mortality (OR: 3.35, 95% CI: 2.75, 3.93; p < 0.001). Conclusions: Blood transfusion is used at a high rate in cardiovascular surgeries, and it was associated with increases in the risk of in-hospital and 1-year all-cause mortality. However, these correlations should be viewed with caution as emergent phenomena rather than causative. Understanding factors associated with the need for blood transfusion can assist surgeons in predicting the outcomes of cardiovascular surgery and in tailoring procedures as needed to optimize outcomes.

Red Blood Cell Transfusion and Pulmonary Complications: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

BACKGROUND

Intraoperative packed red blood cell (PRBC) transfusion during cardiac surgery is associated with increased postoperative morbidity and mortality; however, data on the association between PRBC transfusion and postoperative pulmonary complications (PPCs) are somewhat conflicting. Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, we sought to determine whether intraoperative PRBC transfusion was associated with PPCs as well as with longer intensive care unit (ICU) stay after isolated coronary artery bypass grafting (CABG) surgery.

METHODS

A registry-based cohort study was performed on 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of PPCs (hospital-acquired pneumonia [HAP], mechanical ventilation for >24 hours, or reintubation), ICU length of stay, and ICU readmission.

RESULTS

Transfusion of 1, 2, 3, and ≥4 units of PRBCs was associated with increased odds for HAP (odds ratios [ORs], 1.24 [95% CI, 1.21-1.26], 1.28 [95% CI, 1.26-1.32], 1.36 [95% CI, 1.33-1.39], 1.31 [95% CI, 1.28-1.34]), reintubation (ORs, 1.23 [95% CI, 1.21-1.25], 1.38 [95% CI, 1.35-1.40], 1.57 [95% CI, 1.55-1.60], 1.70 [95% CI, 1.67-1.73]), prolonged ventilation (ORs, 1.34 [95% CI, 1.33-1.36], 1.56 [95% CI, 1.53-1.58], 1.97 [95% CI, 1.94-2.00], 2.27 [95% CI, 2.24-2.30]), initial ICU length of stay (mean difference in hours, 6.79 [95% CI, 6.00-7.58], 9.55 [95% CI, 8.71-10.38], 17.26 [95% CI, 16.38-18.15], 22.14 [95% CI, 21.22-23.06]), readmission to ICU (ORs, 1.14 [95% CI, 1.12-1.64], 1.15 [95% CI, 1.12-1.17], 1.15 [95% CI, 1.13-1.18], 1.32 [95% CI, 1.29-1.35]), and additional ICU length of stay (mean difference in hours, 0.55 [95% CI, 0.18-0.92], 0.38 [95% CI, 0.00-0.77], 1.02 [95% CI, 0.61-1.43], 1.83 [95% CI, 1.40-2.26]), respectively.

CONCLUSIONS

Intraoperative PRBC transfusion was associated with increased incidence of PPCs, prolonged ICU stay, and ICU readmissions after isolated CABG surgery.

Development and validation of a machine learning prediction model for perioperative red blood cell transfusions in cardiac surgery

OBJECTIVE

Several machine learning (ML) models have been used in perioperative red blood cell (RBC) transfusion risk for cardiac surgery with limited generalizability and no external validation. Hence, we sought to develop and comprehensively externally validate a ML model in a large dataset to estimate RBC transfusion in cardiac surgery with cardiopulmonary bypass (CPB).

DESIGN

A retrospective analysis of a multicenter clinical trial (NCT03782350).

PATIENTS

The study patients who underwent cardiac surgery with CPB came from four cardiac centers in China and Medical Information Mart for Intensive Cared (MIMIC-IV) dataset.

MEASUREMENTS

Data from Fuwai Hospital were used to develop an individualized prediction model for RBC transfusion. The model was externally validated in the data from three other centers and MIMIC-IV dataset. Twelve models were constructed.

MAIN RESULTS

A total of 11,201 eligible patients were included in the model development (2420 in Fuwai Hospital) and external validation (563 in the other three centers and 8218 in the MIMIC-IV dataset). A significant difference was observed between the Logistic Regression and CatboostClassifier (0.72 Vs. 0.74, P = 0.031) or RandomForestClassifier (0.72 Vs. 0.75 p = 0.012) in the external validation and MIMIV-IV datasets (age ≤ 70:0.63 Vs. 0.71, p < 0.001; age > 70:0.63 Vs. 0.70, 0.63 Vs. 0.71, p < 0.001). The CatboostClassifier and RandomForestClassifier model was comparable in development (0.83 Vs. 0.82, p = 0.419), external (0.74 Vs. 0.75, p = 0.268), and MIMIC-IV datasets (age ≤ 70: 0.71 Vs. 0.71, p = 0.574; age > 70: 0.70 Vs. 0.71, p = 0.981). Of note, they outperformed other ML models with excellent discrimination and calibration. The CatboostClassifier and RandomForestClassifier models achieved higher area under precision-recall curve and lower brier loss score in validation and MIMIC-IV datasets. Additionally, we confirmed that low preoperative hemoglobin, low body mass index, old age, and female sex increased the risk of RBC transfusion.

CONCLUSIONS

In our study, enrolling a broad range of cardiovascular surgeries with CPB and utilizing a restrictive RBC transfusion strategy, robustly validates the generalizability of ML algorithms for predicting RBC transfusion risk. Notably, the CatboostClassifier and RandomForestClassifier exhibit strong external clinical applicability, underscoring their potential for widespread adoption. This study provides compelling evidence supporting the efficacy and practical value of ML-based approaches in enhancing transfusion risk prediction in clinical practice.

Autologous cell salvage in off-pump coronary artery bypass surgery reduces post-operative complications: a retrospective weighted-matching analysis

OBJECTIVES

Blood transfusion plays a crucial role in coronary artery bypass grafting (CABG). The choice between autologous cell saver (CS) and allogenic blood transfusion (ABT) has been a continuous debate in the medical community, especially within cardiac surgery. This study aimed to assess the outcomes of off-pump CABG (OPCAB) surgery in patients receiving blood solely via cell salvage compared to those receiving ABT or a combination of ABT and CS perioperatively.

METHODS

A total of 414 patients who underwent isolated OPCAB surgery at our cardiovascular clinic were analyzed. Among them, 250 patients (60.4%) received blood via CS alone, while 164 patients (39.6%) received either ABT or a mix of ABT and CS. Stabilized inverse probability treatment weighted (IPTW) matching technique ensured balance in baseline covariates.

RESULTS

We found no significant differences in 30-day mortality rates between the CS and ABT groups. The CS group displayed significantly lower rates of overall complications, encompassing stroke, acute kidney injury, atrial fibrillation, and pulmonary complications. Rates of sepsis, readmission, gastrointestinal complications, heparin-induced thrombosis, and deep venous thrombosis were comparable between the two groups. However, in contrast to the ABT group, the CS group exhibited significantly shorter median lengths of hospital stay (LOHS), ICU stay, and ventilation time, along with higher rates of discharge to home rather than acute care facilities.

CONCLUSION

Our data suggest that autologous blood transfusion via CS results in fewer perioperative complications and faster recovery following OPCAB procedures as compared to ABT.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

The Impact of Pre-Heart Transplantation Blood Transfusion Varies Based on Recipient MELD-XI Score

Prior studies reveal adverse effects of transfusion on cardiac surgery, but little is known of transfusion impact on heart transplantation. First-time, single-organ adult heart transplant recipients between January 1, 2010, and December 31, 2020, were included, stratified above or below a model for end-stage liver disease excluding international normalized ratio (MELD-XI) score of 9.4, and propensity score matched to their nearest neighbor. A 90 day landmark analysis within each cohort was also performed. Unadjusted analysis showed transfusion recipients, MELD-XI ≥9.4, were more likely to experience post-heart transplantation mortality (Hazard Ratio (HR), 1.352 [95% Confidence Interval (CI), 1.239-1.477], p < 0.001), persisting after adjustment for potential confounders (adjusted HR, 1.211 [95% CI, 1.100-1.335], p < 0.001) and after propensity-score matching (HR, 1.174 [95% CI, 1.045-1.319], p = 0.007). Post-transplant length of stay was longer (25.9 vs. 23.2 days, p < 0.001). Post-transplant dialysis was more common (18.7 vs. 15.9%, p = 0.009). There was no survival difference on 90 day landmarked analysis (p = 0.108). With MELD-XI <9.4, there was slight survival detriment among transfusion recipients on univariable analysis (HR, 1.111 [95% CI, 1.001-1.234], p = 0.049) but not on multivariable analysis (adjusted HR, 1.061 [95% CI, 0.952-1.181], p = 0.285). There was similar survival after propensity-score matching (HR, 1.032 [95% CI, 0.903-1.180], p = 0.642) and on landmark analysis (p = 0.581). Ultimately, transfusion was associated with worse post-heart transplantation outcomes among recipients with a MELD-XI ≥9.4.

Platelet Transfusion in Cardiac Surgery: An Entropy-Balanced, Weighted, Multicenter Analysis

BACKGROUND

Platelet transfusion is common in cardiac surgery, but some studies have suggested an association with harm. Accordingly, we investigated the association of perioperative platelet transfusion with morbidity and mortality.

METHODS

We conducted a retrospective analysis of prospectively collected data from the Australian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database. We included consecutive adults from 2005 to 2018 across 40 centers. We used inverse probability of treatment weighting via entropy balancing to investigate the association of perioperative platelet transfusion with our 2 primary outcomes, operative mortality (composite of both 30-day and in-hospital mortality) and 90-day mortality, as well as multiple other clinically relevant secondary outcomes.

RESULTS

Among 119,132 eligible patients, 25,373 received perioperative platelets and 93,759 were considered controls. After entropy balancing, platelet transfusion was associated with reduced operative mortality (odds ratio [OR], 0.63; 99% confidence interval [CI], 0.47-0.84; P < .0001) and 90-day mortality (OR, 0.66; 99% CI, 0.51-0.85; P < .0001). Moreover, it was associated with reduced odds of deep sternal wound infection (OR, 0.57; 99% CI, 0.36-0.89; P = .0012), acute kidney injury (OR, 0.84; 99% CI, 0.71-0.99; P = .0055), and postoperative renal replacement therapy (OR, 0.71; 99% CI, 0.54-0.93; P = .0013). These positive associations were observed despite an association with increased odds of return to theatre for bleeding (OR, 1.55; 99% CI, 1.16-2.09; P < .0001), pneumonia (OR, 1.26; 99% CI, 1.11-1.44; P < .0001), intubation for longer than 24 hours postoperatively (OR, 1.13; 99% CI, 1.03-1.24; P = .0012), inotrope use for >4 hours postoperatively (OR, 1.14; 99% CI, 1.11-1.17; P < .0001), readmission to hospital within 30 days of surgery (OR, 1.22; 99% CI, 1.11-1.34; P < .0001), as well as increased drain tube output (adjusted mean difference, 89.2 mL; 99% CI, 77.0 mL-101.4 mL; P < .0001).

CONCLUSIONS

In cardiac surgery patients, perioperative platelet transfusion was associated with reduced operative and 90-day mortality. Until randomized controlled trials either confirm or refute these findings, platelet transfusion should not be deliberately avoided when considering odds of death.

Effect of topical application of autologous platelet gel on sternal wound infection after cardiac surgery: A meta-analysis

Following heart operation, a severe life-threatening complication has been identified by investigators who have recently discovered that local application of platelet-rich plasma (PRP) can lower the rate of wound infection in heart surgery. Nevertheless, due to the low quality of these trials, we have tried to perform high-quality meta-analyses to prove the efficacy of PRP in heart surgery for post-operative wound infections. In this study, five randomised controlled trials (RCTs) were chosen from three databases, and there were 1005 studies to analyse the data. Among 181 cases, PRP was applied to the surgical site, and 205 in the control group. Both the CI and the OR or the average difference (MD) were computed with either a fixed or random-effect model. A meta-analysis of the data was carried out with RevMan 5.3. The results showed that there were no statistically significant differences in the incidence of post-operative surgical site infection (SSI) in control group compared to those treated with PRP gel (OR, 0.97; 95% CI, 0.38, 2.47; p = 0.95); In the heart operation, the local application of PRP gel decreased the rate of drainage after operation (MD, -217.82; 95% CI, -335.38, -100.26; p = 0.0003); The operation time of the PRP gel was not significantly different from that of the control group (MD, 12.65; 95% CI, -2.95, 28.24; p = 0.11). Contrary to earlier research, the application of autoplatelet gel in heart surgery did not seem to decrease operative site infections after the operation, but it did decrease the amount of postoperative drainage. Nevertheless, because of the limited number of RCTs in this meta-analysis, caution should be exercised in their treatment. More high-quality randomised, large-sample trials are required to further confirm the findings.

Postoperative anemia in cardiac surgery patients: a narrative review

PURPOSE

Anemia reduces the blood's ability to carry and deliver oxygen. Following cardiac surgery, anemia is very common and affects up to 90% of patients. Nevertheless, there is a paucity of data examining the prognostic value of postoperative anemia. In this narrative review, we present findings from the relevant literature on postoperative anemia in cardiac surgery patients, focusing on the incidence, risk factors, and prognostic value of postoperative anemia. We also explore the potential utility of postoperative anemia as a therapeutic target to improve clinical outcomes.

SOURCE

We conducted a targeted search of MEDLINE, Embase, and the Cochrane Database of Systematic Reviews up to September 2022, using a combination of search terms including postoperative (post-operative), perioperative (peri-operative), anemia (anaemia), and cardiac surgery.

PRINCIPAL FINDINGS

The reported incidence of postoperative anemia varied from 29% to 94% across the studies, likely because of variations in patient inclusion criteria and classification of postoperative anemia. Nonetheless, the weight of the evidence suggests that postoperative anemia is common and is an independent risk factor for adverse postoperative outcomes such as acute kidney injury, stroke, mortality, and functional outcomes.

CONCLUSIONS

In cardiac surgery patients, postoperative anemia is a common and prognostically important risk factor for postoperative morbidity and mortality. Nevertheless, there is a lack of data on whether active management of postoperative anemia is feasible or effective in improving patient outcomes.

Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease.

METHODS

A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up.

RESULTS

A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS.

CONCLUSIONS

MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.

Predicting the Need for Blood Transfusions in Cardiac Surgery: A Comparison between Machine Learning Algorithms and Established Risk Scores in the Brazilian Population

INTRODUCTION

Blood transfusion is a common practice in cardiac surgery, despite its well-known negative effects. To mitigate blood transfusion-associated risks, identifying patients who are at higher risk of needing this procedure is crucial. Widely used risk scores to predict the need for blood transfusions have yielded unsatisfactory results when validated for the Brazilian population.

METHODS

In this retrospective study, machine learning (ML) algorithms were compared to predict the need for blood transfusions in a cohort of 495 cardiac surgery patients treated at a Brazilian reference service between 2019 and 2021. The performance of the models was evaluated using various metrics, including the area under the curve (AUC), and compared to the commonly used Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST) scoring systems.

RESULTS

The study found that the model had the highest performance, achieving an AUC of 0.7350 (confidence interval [CI]: 0.7203 to 0.7497). Importantly, all ML algorithms performed significantly better than the commonly used TRACK and TRUST scoring systems. TRACK had an AUC of 0.6757 (CI: 0.6609 to 0.6906), while TRUST had an AUC of 0.6622 (CI: 0.6473 to 0.6906).

CONCLUSION

The findings of this study suggest that ML algorithms may offer a more accurate prediction of the need for blood transfusions than the traditional scoring systems and could enhance the accuracy of predicting blood transfusion requirements in cardiac surgery patients. Further research could focus on optimizing and refining ML algorithms to improve their accuracy and make them more suitable for clinical use.

Incorporation of Blood and Fluid Management Within an Enhanced Recovery after Surgery Protocol in Complex Spine Surgery

STUDY DESIGN

retrospective review.

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery.

METHODS

A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay.

RESULTS

Following implementation, the rate of blood transfusion decreased by 11.7%(P = .017) and average crystalloid infusion was reduced 680 mL per case(P < .001). Intraoperative blood loss decreased on average 342 mL per case(P = .001) and TXA use increased significantly by 25%(P < .001). Postoperative ICU admissions declined by 8.5%(P = .071); extubation within the OR increased by 13.3%(P = .005).

CONCLUSIONS

This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

What drives variability in postoperative cardiac surgery transfusion rates?

OBJECTIVE

Wide interhospital variation exists in cardiac surgical postoperative transfusion rates. We aimed to compare transfusion rates at 2 hospitals and identify the institutional practice factors, unrelated to patient or operative characteristics, associated with postoperative transfusion rates.

METHODS

Records for adult patients undergoing routine cardiac surgery at 2 hospitals (H and L) from February 2020 to August 2022 were analyzed. Patient and operative characteristics, preoperative and intensive care unit hemoglobin values, and postoperative transfusion rates were compared. Transfusion indication was recorded prospectively. Propensity matching was completed to assess comparability of patient populations.

RESULTS

After propensity matching patients at H and L on age, procedure type, predicted morbidity or mortality, crossclamp time, preoperative hypertension, preoperative heart failure, and preoperative stroke, 2111 patients remained, with similar characteristics except hypertension. Matched results showed no significant differences in mortality, reoperation, or other major outcomes. Hospital H transfused 36% of patients (mean postoperative hemoglobin [Hb] 10.5) with 1483 units of packed red blood cells whereas hospital L transfused 12% of patients (mean postoperative Hb 9.4) with 198 units of packed red blood cells (P < .001). For all patients with a Hb >7.5, hospital H versus L transfused 27% versus 0.9% (P < .001). Hospital L's sole transfusion indication for pretransfusion hemoglobin trigger >7.5 was bleeding versus hospital H, which had multiple indications. When Hb concentration alone was the indication for transfusion, the threshold at hospital H was <7.5 g/dL versus <6 g/dL at hospital L.

CONCLUSIONS

Variation in transfusion rates between hospitals H and L resulted from strict adherence at hospital L to a transfusion trigger of <6 g/dL with narrow indications for transfusions above that Hb concentration.

Influence of preoperative and intraoperative factors on recovery after aortic root surgery

OBJECTIVE

To determine the influence of intraoperative factors relative to preoperative risk factors on recovery after aortic root replacement (ARR).

METHODS

Retrospective review of baseline and intraoperative characteristics was performed of 822 patients at our Aortic Center from 2005 to 2019. Inclusion criteria were all patients age 18 and older who underwent ARR at our institution from 2005 to 2019. The primary endpoint was the aggregate outcome of "failure to achieve uneventful recovery (FUR)," as previously defined.

RESULTS

In total, 207 (25%) patients experienced FUR. The following preoperative and intraoperative variables were significantly associated with FUR in the multivariable analysis: cardiopulmonary bypass time (OR 1.01, 95% CI 1.01-1.02) open chest management (OR 5.67, 95% CI 2.65-12.1), ejection fraction (OR 1.03, 95% CI 1.01-1.04), chronic kidney disease > stage 3a (OR 2.37, 95% CI 1.54-3.63), bicuspid aortic valve (OR 1.54, 95% CI 1.21-1.96), and female sex (OR 1.30, 95% CI 1.06-1.61). Cardiopulmonary bypass time and open chest management were among the top three partial R2 contributors to the logistic regression model variance.

CONCLUSIONS

These findings suggest efficacy in using intraoperative parameters to predict postoperative outcomes after ARR.

Cost-Effectiveness and Budget Impact Analyses of Patient Blood Management in a Cardiovascular Surgery Department at Ankara Bilkent City Hospital in Turkey

INTRODUCTION

Anemia and transfusion of blood products are risk factors associated with poor patient outcomes across all elective surgeries. Patient blood management (PBM) is a patient-centered approach to optimize patient's endogenous red cell mass, to minimize blood loss in patients undergoing surgery, and to harness and optimize patient-specific physiological tolerance to anemia. This study aimed to assess (1) the impact of PBM on blood product usage in cardiovascular surgeries in a state hospital setting, (2) cost-effectiveness of PBM with a model based on transfusion of red blood cells (RBCs) in cardiovascular surgeries, and (3) the budget impact of PBM implementation based on transfusion of RBCs.

METHODS

Cost-effectiveness and budget impact models, based on the numbers of avoided transfusions and avoided complications after implementation of the PBM program, were compared between pre- and post-PBM periods at the cardiovascular surgery department of Ankara Bilkent City Hospital between February 11, 2019 and July 24, 2022. The probabilities of transfusions and complications with and without PBM were taken from recent meta-analyses. Data from the Ankara Bilkent City Hospital transfusion center informed the pre- and post-PBM calculations. Costs were calculated from the Social Security Institution's perspective.

RESULTS

There was a 21% decrease in the use of RBCs and a 23.7% decrease in use of all blood products after the implementation of PBM. The number of RBC packs per patient reduced by 0.88 packs (21%). The cost saving from reduction of RBC transfusions per patient was 518.68 Turkish lira (TRY) and for the hospital it was 1,635,948 TRY. Fewer complications and lower costs in favor of the post-PBM arm were demonstrated in the cost-effectiveness analysis. On the basis of the budget impact model, in 20 months, the hospital's cardiovascular surgery department saved 6,596,934 TRY (€342,302).

CONCLUSION

This hospital-based study demonstrated that PBM is a budget-saving and cost-effective option in Turkey.

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

Background

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

Methods

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

Results

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

Conclusion

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

Risk factors for perioperative blood transfusion in patients undergoing total laparoscopic hysterectomy

PURPOSE

The goal is to identify risk factors associated with receiving a blood transfusion during the perioperative period in patients who undergo total laparoscopic hysterectomy (TLH) using a large-scale national database.

METHODS

In this retrospective analysis, data from the Nationwide Inpatient Sample (NIS) was utilized to review the medical records of all patients who underwent TLH from 2010 to 2019. The researchers identified patients who had received a blood transfusion during the perioperative period and compared with those who had not. The subsequent factors associated with blood transfusion were examined: hospital characteristics (type of admission and payer, patient demographics (age and race), bed size, teaching status, location, and region of hospital), length of stay (LOS), total charges during hospitalization, in-hospital mortality, comorbidities, and perioperative complications. The data was analyzed using descriptive statistics. The independent risk factors of perioperative blood transfusion after TLH was identified by performing multivariate logistic regression.

RESULTS

A total of 79,933 TLH were captured from the NIS database, among which 3433 (4.40%) patients received a perioperative blood transfusion. TLH patients affected by blood transfusion were 2 days longer hospital stays (P < 0.001), higher overall costs (P < 0.001), the patients who received a transfusion after a long-term hospitalization had a significantly higher rate of mortality (0.5% vs. 0.1%; P < 0.001). Perioperative blood transfusion after TLH was associated with chronic blood loss anemia, deficiency anemia, coagulopathy, congestive heart failure, fluid and electrolyte disorders, renal failure, metastatic cancer, sepsis, weight loss, deep vein thrombosis, gastrointestinal hemorrhage, shock, acute myocardial infarction, and pneumonia, stroke, hemorrhage, pulmonary embolism, and disease of the genitourinary system.

CONCLUSION

Studying the risk factors of perioperative blood transfusion after TLH is advantageous in order to ensure proper management and optimize outcomes.

Prothrombin Complex Concentrate versus Fresh Frozen Plasma in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis

Background

Prothrombin complex concentrate (PCC) and fresh frozen plasma (FFP) are commonly used to manage bleeding in patients during cardiac surgery. However, the relative efficacy and safety of these 2 strategies remain uncertain.

Methods

MEDLINE, Embase, and Cochrane were searched for studies comparing PCC and FFP in patients who underwent cardiac surgery complicated by bleeding. Review Manager (RevMan) ver. 5.4 (Nordic Cochrane Centre, The Cochrane Collaboration) was used for statistical analysis. Binary and continuous outcomes were compared using pooled risk ratios and mean differences, respectively. The meta-analysis protocol was registered in the International Prospective Register of Systematic Reviews under protocol number CRD42022379144.

Results

We included 8 studies with 1,500 patients, of whom 613 (40.9%) received PCC. The mean follow-up period ranged from 28 to 90 days. The PCC group had significantly lower chest tube drainage at 24 hours (mean difference [MD], -148.50 mL; 95% CI, -253.02 to -43.99 mL; p=0.005; I2=42%). Fewer units of red blood cells (RBCs) were transfused within the first 24 hours (MD, -1.02 units; 95% CI, -1.81 to -0.24 units; p=0.01; I2=56%), and fewer patients required RBC transfusion within the first 24 hours (risk ratio, 0.85; 95% CI, 0.78-0.93; p<0.007; I2=45%) in the PCC group. There were no statistically significant differences in secondary outcomes. Nonetheless, a subgroup analysis of randomized controlled trials failed to corroborate the results obtained from the main analysis.

Conclusion

Our findings suggest that PCC can be effective, without increased adverse events, when compared with FFP in patients undergoing cardiac surgery complicated by bleeding.

Prospective, Randomized Study of Fibrinogen Concentrate Versus Cryoprecipitate for Correcting Hypofibrinogenemia in Cardiac Surgery Patients

OBJECTIVE

Cardiac surgery with cardiopulmonary bypass (CPB) is associated with hypofibrinogenemia and severe bleeding requiring transfusion. Guidelines recommend cryoprecipitate or fibrinogen concentrate (FC) for the treatment of acquired hypofibrinogenemia. This study compared cryoprecipitate and FC for the correction of acquired hypofibrinogenemia and the associated costs.

DESIGN

A single-center, prospective, randomized study evaluating patients with hypofibrinogenemia after cardiac surgery. The primary endpoint was direct treatment cost. Secondary endpoints included the change in fibrinogen level after FC and/or cryoprecipitate dosing.

SETTING

A single-center study in Astana, Kazakhstan.

PARTICIPANTS

Participants who underwent CPB from 2021 to 2022 and developed clinically significant bleeding and hypofibrinogenemia.

INTERVENTIONS

Patients were randomized to receive cryoprecipitate or FC.

MEASUREMENTS AND MAIN RESULTS

Eighty-eight adult patients with acquired hypofibrinogenemia (<2.0 g/L) after CPB were randomized to receive cryoprecipitate (N = 40) or FC (N = 48), with similar demographics between groups. Overall, mean ± SD 9.33 ± 0.94 units (range, 8-10) cryoprecipitate or 1.40 ± 0.49 g (1-2) FC was administered to the 2 groups. From before administration to 24 hours after, mean plasma fibrinogen increased by a mean ± SD of 125 ± 65 and 96 ± 65 mg/dL in the cryoprecipitate and FC groups, respectively. At 48 hours after administration, there was no significant difference in fibrinogen levels between groups. The mean direct cost of treatment with FC was significantly lower than with cryoprecipitate (p < 0.0001): $1,505.06 ± $152.40 and $631.75 ± $223.67 per patient for cryoprecipitate and FC, respectively.

CONCLUSION

Analysis of plasma fibrinogen concentration showed that cryoprecipitate and FC had comparable effectiveness. However, FC is advantageous over cryoprecipitate due to its ease of handling, lower cost, and high purity.

Transfusion of non-red blood cell blood products does not reduce survival following cardiac surgery

OBJECTIVES

The literature supports the assertion that patients undergoing cardiac surgery who receive perioperative packed red blood cell (pRBC) transfusions have increased associated mortality. The aim of the current study is to assess whether there is an association between non-pRBC blood product transfusions and increased mortality.

METHODS

Data from our center's Society of Thoracic Surgeons database included patients who underwent cardiac surgery from 2010 to 2018. Patients with pRBC transfusions or circulatory arrest were excluded. Propensity matching was performed (1:1; caliper = 0.2 times the standard deviation of logit of propensity score). Kaplan-Meier estimates and Cox regression were used. Cardiac transplant, ventricular assist devices, transcatheter aortic valves, and patients who had experienced circulatory arrest were excluded from this analysis.

RESULTS

A total of 8042 patients met criteria for analysis. Following propensity matching (1:1), 395 patients requiring perioperative non-pRBC blood products (platelets, fresh-frozen plasma, and cryoprecipitate) were matched with 395 nontransfusion patients, yielding equitable patient cohorts. Median follow-up was 4.5 (3.0-6.4) years. Patients received platelets (327 [82.8%]), fresh-frozen plasma (141 [35.7%]), and cryoprecipitate (60 [15.2%]). There was no significant difference in the postoperative mortality (6 [1.5%] vs 4 [1.0%]; P = .52). Reoperation (20 [5.0%] vs 8 [2.0%]; P < .02) and prolonged ventilation (36 [9.1%] vs 19 [4.8%]; P < .02) were greater in the transfusion group. Emergent operation (odds ratio [OR] 2.86 [1.72-4.78]; P < .001), intra-aortic balloon pump (OR 3.24 [1.64-6.39]; P < .001), and multivalve operation (OR 4.34 [2.83-6.67]; P < .001) were significantly associated with blood product use. Blood product transfusion (hazard ratio; 1.15 [0.89-1.48]; P = .3) was not significantly associated with increased mortality risk. There was no significant long-term survival difference between cohorts.

CONCLUSIONS

Patients who undergo cardiac surgery requiring blood products alone, without pRBC transfusion, have similar postoperative and long-term survival compared with patients not requiring blood products. These data are based on a limited patient sample, and future studies will aid in improving the generalizability of these results.

Risk stratification model integrating nutritional and inflammatory factors for predicting 1-year mortality after valvular heart surgery: a retrospective cohort study

INTRODUCTION

Existing risk-scoring systems for cardiac surgery include only standard preoperative factors without considering nutritional and inflammatory status or intraoperative factors. The objective of this study was to develop a comprehensive prediction model for mortality incorporating nutritional, inflammatory, and perioperative factors in patients undergoing valvular heart surgery.

MATERIALS AND METHODS

In this retrospective review of 2046 patients who underwent valvular heart surgery, Cox and LASSO regression analyses were performed to identify independent prognostic factors for 1-year postoperative mortality among various perioperative factors known to affect prognosis, including objective nutritional and inflammatory indices. A novel nomogram model incorporating selected prognostic factors was developed, and its discrimination ability was evaluated using the C-index. The model was validated in internal and external cohorts.

RESULTS

The 1-year mortality rate after valvular heart surgery was 5.1% (105 of 2046 patients) and was significantly associated with several preoperative objective inflammatory and nutritional indices. Cox and LASSO analyses identified the following five independent prognostic factors for mortality: monocyte-to-lymphocyte ratio (an objective inflammatory index), EuroSCORE II, Controlling Nutritional Status score, cardiopulmonary bypass time, and number of erythrocyte units transfused intraoperatively. The nomogram model incorporating these five factors had a C-index of 0.834 (95% CI: 0.791-0.877), which was higher than that of EuroSCORE II alone (0.744, 95% CI: 0.697-0.791) ( P <0.001). The nomogram achieved good discrimination ability, with C-indices of 0.836 (95% CI: 0.790-0.878) and 0.727 (95% CI: 0.651-0.803) in the internal and external validation cohorts, respectively, and showed well-fitted calibration curves.

CONCLUSIONS

A nomogram model incorporating five inflammatory, nutritional, and perioperative factors, as well as EuroSCORE II, was a better predictor of 1-year mortality after valvular heart surgery than EuroSCORE II alone, with good discrimination and calibration power for predicting mortality in both internal and external validation cohorts.

Short-Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation serves as a crucial mechanical circulatory support for pediatric patients with severe heart diseases, but the mortality rate remains high. The objective of this study was to assess the short-term mortality in these patients.

METHODS AND RESULTS

We systematically searched PubMed, Embase, and Cochrane Library for observational studies that evaluated the short-term mortality of pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation. To estimate short-term mortality, we used random-effects meta-analysis. Furthermore, we conducted meta-regression and binomial regression analyses to investigate the risk factors associated with the outcome of interest. We systematically reviewed 28 eligible references encompassing a total of 1736 patients. The pooled analysis demonstrated a short-term mortality (defined as in-hospital or 30-day mortality) of 45.6% (95% CI, 38.7%-52.4%). We found a significant difference (P<0.001) in mortality rates between acute fulminant myocarditis and congenital heart disease, with acute fulminant myocarditis exhibiting a lower mortality rate. Our findings revealed a negative correlation between older age and weight and short-term mortality in patients undergoing veno-arterial extracorporeal membrane oxygenation. Male sex, bleeding, renal damage, and central cannulation were associated with an increased risk of short-term mortality.

CONCLUSIONS

The short-term mortality among pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation for severe heart diseases was 45.6%. Patients with acute fulminant myocarditis exhibited more favorable survival rates compared with those with congenital heart disease. Several risk factors, including male sex, bleeding, renal damage, and central cannulation contributed to an increased risk of short-term mortality. Conversely, older age and greater weight appeared to be protective factors.

Sex Differences in Red Blood Cell Transfusions and 30-Day Mortality in Cardiac Surgery: A Single Center Observational Study

In cardiac surgery, women have higher short-term mortality and a higher risk of receiving red blood cell (RBC) transfusions than men. This study's aim was to evaluate possible sex differences in RBC transfusions in cardiac surgery and their association with preoperative hemoglobin levels, body mass index, and 30-day mortality. A single-center retrospective study was conducted with 1583 patients (1181 men and 402 women) undergoing cardiac surgery. A total of 64.4% of the women and 33.0% of the men received an RBC transfusion. In a multivariable analysis, female sex was an independent predictor of RBC transfusion (OR 3.88, 95% CI 2.95-5.11, p < 0.001). Other independent predictors of RBC transfusion were age, preoperative hemoglobin level, and body mass index. The women were more likely to receive RBC transfusions than the men, regardless of the type of cardiac surgery. Decreased transfusion risk was found in all higher-than-normal weight categories in the women, but only in the severe obesity category in the men. Preoperative hemoglobin was similarly associated with RBC transfusion in the men and women. The crude 30-day mortality rate was higher in the women than in the men (2.5% vs. 0.9%, p = 0.018). In both sexes, RBC transfusion was associated with an increased probability of death within 30 days.

Outcomes following perioperative red blood cell transfusion in patients undergoing elective major abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Perioperative red blood cell transfusion is a double-edged sword for surgical patients. While transfusion of red cells can increase oxygen delivery by increasing haemoglobin levels, its impact on short- and long-term postoperative outcomes, particularly in patients undergoing elective major abdominal surgery, is unclear.

METHODS

We conducted a systematic review and meta-analysis on the effect of perioperative blood transfusions on postoperative outcomes in elective major abdominal surgery. PubMed, Cochrane, and Scopus databases were searched for studies with data collected between January 1, 2000 and June 6, 2020. The primary outcome was short-term mortality, including all-cause 30-day or in-hospital mortality. Secondary outcomes included long-term all-cause mortality, any morbidity, infectious complications, overall survival, and recurrence-free survival. No randomised controlled trials were found. Thirty-nine observational studies were identified, of which 37 were included in the meta-analysis.

RESULTS

Perioperative blood transfusion was associated with short-term all-cause mortality (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.89-3.91, P<0.001), long-term all-cause mortality (hazard ratio 1.35, 95% CI 1.09-1.67, P=0.007), any morbidity (OR 2.18, 95% CI 1.81-2.64, P<0.001), and infectious complications (OR 1.90, 95% CI 1.60-2.26, P<0.001). Perioperative blood transfusion remained associated with short-term mortality in the sensitivity analysis after excluding studies that did not control for preoperative anaemia (OR 2.27, 95% CI 1.59-3.24, P<0.001).

CONCLUSIONS

Perioperative blood transfusion in patients undergoing elective major abdominal surgery is associated with poorer short- and long-term postoperative outcomes. This highlights the need to implement patient blood management strategies to manage and preserve the patient's own blood and reduce the need for red blood cell transfusion.

TRIAL REGISTRATION

PROSPERO (CRD42021254360).

Using machine learning to predict bleeding after cardiac surgery

OBJECTIVES

The primary objective was to predict bleeding after cardiac surgery with machine learning using the data from the Australia New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database, cardiopulmonary bypass perfusion database, intensive care unit database and laboratory results.

METHODS

We obtained surgical, perfusion, intensive care unit and laboratory data from a single Australian tertiary cardiac surgical hospital from February 2015 to March 2022 and included 2000 patients undergoing cardiac surgery. We trained our models to predict either the Papworth definition or Dyke et al.'s universal definition of perioperative bleeding. Our primary outcome was the performance of our machine learning algorithms using sensitivity, specificity, positive and negative predictive values, accuracy, area under receiver operating characteristics curve (AUROC) and area under precision-recall curve (AUPRC).

RESULTS

Of the 2000 patients undergoing cardiac surgery, 13.3% (226/2000) had bleeding using the Papworth definition and 17.2% (343/2000) had moderate to massive bleeding using Dyke et al.'s definition. The best-performing model based on AUPRC was the Ensemble Voting Classifier model for both Papworth (AUPRC 0.310, AUROC 0.738) and Dyke definitions of bleeding (AUPRC 0.452, AUROC 0.797).

CONCLUSIONS

Machine learning can incorporate routinely collected data from various datasets to predict bleeding after cardiac surgery.

Computed tomography defined femoral artery plaque composition predicts vascular complications during transcatheter aortic valve implantation

OBJECTIVE

Vascular and bleeding complications after transcatheter aortic valve implantation (TAVI) are common and lead to increased morbidity and mortality. Analysis of plaque at the arterial access site may improve prediction of complications.

METHODS

We investigated the association between demographic and procedural risk factors for Valve Academic Research Consortium (VARC-3) vascular complications in patients undergoing transfemoral TAVI with use of a vascular closure device (ProGlide® or MANTA®) in this retrospective cohort study. The ability of pre-procedure femoral CT angiography to predict complications was investigated including a novel method of quantifying plaque composition of the common femoral artery using plaque maps created with patient specific X-ray attenuation cut-offs.

RESULTS

23 vascular complications occurred in the 299 patients in the study group (7.7%). There were no demographic risk factors associated with vascular complications and no statistical difference between use of closure device (ProGlide® vs MANTA®) and vascular complications. Vascular complications after TAVI were associated with sheath size (OR 1.36, 95% CI 1.08-1.76, P 0.01) and strongly associated with CT-derived necrotic core volume in the common femoral artery of the procedural side (OR 17.49, 95% CI 1.21-226.60, P 0.03).

CONCLUSION

Plaque map analysis of the common femoral artery by CT angiography reveals patients with greater necrotic core are at increased risk of VARC-3 vascular complications.

ADVANCES IN KNOWLEDGE

The novel measurement of necrotic core volume in the common femoral artery on the procedural side by CT analysis was associated with post-TAVI vascular complications, which can be used to highlight increased risk.

Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia

BACKGROUND

Reducing the need for blood transfusion among patients undergoing cardiac surgery FLA reduce postoperative complications and mortality. Our study aimed to assess the effects of administering preoperative i.v. ferric carboxymaltose on postoperative red cell transfusion requirements in patients without anaemia undergoing on-pump cardiac surgery.

METHODS

This double-blind, randomised, placebo-controlled trial was conducted between October 2016 and November 2019, with a follow-up period of up to 6 weeks after surgery. Patients without anaemia who underwent on-pump cardiac surgery were included as participants and administered i.v. iron in the form of ferric carboxymaltose or placebo once, 24-72 h before surgery. The primary outcome was the number of red cell units transfused during the first four postoperative days, and the secondary outcome measures were blood haemoglobin concentrations at 4 days and 6 weeks after surgery.

RESULTS

The 200 patients included were randomly assigned to the ferric carboxymaltose (n=102) and placebo (n=98) groups. By postoperative Day 4, a significantly lower mean number of red cell units were transfused in the ferric carboxymaltose than in the placebo group, 0.3 (0.8) vs 1.6 (4.4), respectively; P=0.007. The mean haemoglobin concentrations on postoperative Day 4 were 9.7 (1) g dl-1 and 9.3 (1) g dl-1, respectively (P=0.03). Corresponding values at 6 weeks after surgery were 12.6 (1.4) g dl-1 and 11.8 (1.5) g dl-1, respectively (P=0.012).

CONCLUSIONS

In patients without anaemia undergoing on-pump cardiac surgery, treatment with a single dose of 1000 mg ferric carboxymaltose i.v. 1-3 days before surgery significantly reduced the need for red cell transfusions and increased the postoperative haemoglobin concentration.

CLINICAL TRIAL REGISTRATION

NCT02939794.

An in vitro comparison of intra-operative isohemagglutinin and human leukocyte antigen removal techniques in pediatric heart transplantation

BACKGROUND

Highly sensitized pediatric patients awaiting heart transplantation experience longer wait times and thus higher waitlist mortality. Similarly, children less than 2 years of age have increased waitlist times and mortality when compared to their older peers. To improve the likelihood of successful transplantation in these patients, various strategies have been utilized, including peri-operative plasmapheresis. However, limited data exists comparing plasmapheresis techniques for antibody reduction. This study's aim was to compare the in vitro magnitude of isohemagglutinin titers (IT) and human leukocyte antigen (HLA) antibody removal and the time required between membrane-based plasmapheresis (MP) and centrifuge-based plasmapheresis (CP) incorporated into the extracorporeal (EC) circuit.

METHODS

Two MP (Prismaflex) and two CP (Spectra Optia, Terumo BCT) circuits were incorporated into four separate EC circuits primed with high titer, highly sensitized type O donor whole blood. Assays were performed to determine baseline IT and anti-HLA antibodies and then at 30-minute increments until completion of the run (two plasma volume exchanges) at two hours.

RESULTS

There was a decrease in anti-A and anti-B IgM and IgG titers with both MP and CP. Mean anti-A and anti-B titer reduction was by 4.625 titers (93.7% change) and 4.375 titers (93.8% change) using MP and CP, respectively. At 2 h of apheresis, CP reduced 62.5% of all ITs to ≤ 1:4, while MP reduced 50% of ITs to ≤ 1:4. Additionally, reduction of anti-HLA class II antibody to mean fluorescence intensity (MFI) <3000 was achieved with both MP and CP. At 2 h of apheresis, CP reduced MFI by 2-3.5 fold and MP reduced MFI by 1.7-2.5 fold. Both demonstrated similar hemolytic and thrombotic profiles.

CONCLUSIONS

In this in vitro plasmapheresis model of IT and anti-HLA antibody reduction, both MP and CP incorporated into the EC circuit can be used quickly and effectively to reduce circulating antibodies. While CP may have some greater efficiency, further study is necessary to verify this in vivo.

Implementation of a Short-term Treatment Protocol in Anemic Patients before Cardiac Surgery

BACKGROUND

 We assessed whether implementation of an immediate preoperative treatment in anemic patients could result in fewer perioperative packed red blood cell (PRBC) transfusions and improved outcomes in a real-world setting.

METHODS

 From January 1, 2020, to November 31, 2022, we implemented a perioperative protocol for anemic patients (hemoglobin (Hb) level in women <11.5 g/dL, men <12.5 g/dL), which included subcutaneous erythropoietin α, intravenous Iron, and intramuscular vitamin B12 (all given preoperatively) and per os iron and folic acid given once a day postoperatively. We retrospectively compared all patients receiving the protocol to all eligible patients who were operated upon in the 4 years prior to implementation of the protocol. Primary outcome was amount of PRBC transfusions during surgery and index admission.

RESULTS

 In the months after protocol implementation, 114 patients who received the treatment protocol were compared with 236 anemic patients in the 4 years prior to who did not receive the protocol. The treatment reduced total PRBC use (control group median 4 [2-7] units vs. treatment 2 [1-3] units, p < 0.0001) and the incidence of postoperative blood products transfusions (treatment group 58 patients, 50.88% vs. control group 177 patients, 75%, p < 0.0001). Hb prior to discharge was higher among the protocol group (treatment median 9 g/dL [8.3-9.5 g/dL] vs. control 8.6 g/dL [8.1-9.1 g/dL], p = 0.0081).

CONCLUSION

 Despite some differences compared with previously described protocols, the implementation of a perioperative treatment protocol for anemic patients was associated with a reduction in PRBC transfusion in a real-world setting.

A model based on electronic health records to predict transfusion events in on-pump cardiac surgery

Perioperative blood transfusion is costly and raises safety concerns. We developed and validated a model for predicting minor, moderate, or major transfusion given to patients during on-pump cardiac procedures based on two centers' database. Model performance incorporating 7 variables on the development set had an AUC of 0.803 [95% CI, 0.790-0.815] for minor transfusion; moderate transfusion, giving an AUC of 0.822 (95% CI, 0.803-0.841); and major transfusion, giving an AUC of 0.813 (95% CI, 0.759-0.866). Model performance on the validation set had an AUC of 0.739 (95% CI 0.714-0.765), 0.730 (95% CI 0.702-0.758), and 0.713 (95% CI 0.677-0.749), respectively. A model based entirely on readily available electronic health records can accurately predict intraoperative minor, moderate, or major transfusion and provide individualized transfusion risk profiles before surgery among those on-pump cardiac surgical patients, and may help guide patient management.

Evaluation of the validated intraoperative bleeding scale in liver surgery: study protocol for a multicenter prospective study

Background

Surgical hemostasis has become one of the key principles in the advancement of surgery. Hemostatic agents are commonly administered in many surgical specialties, although the lack of consensus on the definition of intraoperative bleeding or of a standardized system for its classification means that often the most suitable agent is not selected. The recommendations of international organizations highlight the need for a bleeding severity scale, validated in clinical studies, that would allow the selection of the best hemostatic agent in each case. The primary objective of this study is to evaluate the VIBe scale (Validated Intraoperative Bleeding Scale) in humans. Secondary objectives are to evaluate the scale's usefulness in liver surgery; to determine the relationship between the extent of bleeding and the hemostatic agent used; and to assess the relationship between the grade of bleeding and postoperative complications.

Methods

Prospective multicenter observational study including 259 liver resections that meet the inclusion criteria: patients scheduled for liver surgery at one of 10 medium-high volume Spanish HPB centers using an open or minimally invasive approach (robotic/laparoscopic/hybrid), regardless of diagnosis, ASA score <4, age ≥18, and who provide signed informed consent during the study period (September 2023 until the required sample size has been recruited). The participating researchers will be responsible for collecting the data and for reporting them to the study coordinators.

Discussion

This study will allow us to evaluate the VIBe scale for intraoperative bleeding in humans, with a view to its subsequent incorporation in daily clinical practice.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT05369988?term = serradilla&draw = 2&rank = 3, [NCT0536998].

Dose-dependent influence of red blood cell transfusion volume on adverse outcomes in cardiac surgery

INTRODUCTION

Red blood cell (RBC) transfusion is associated with adverse outcomes, but there are few studies on the RBC volume. This study aimed to evaluate the relationship between intraoperative RBC volume and postoperative adverse outcomes for on-pump cardiac surgery.

METHODS

Adult patients undergoing on-pump cardiac surgery from 1 January 2017 to 31 December 2018 were included. Those transfused with more than 6 units of RBC were excluded. The clinical characteristics of four groups with various RBC volume were compared. We analyzed the relationship between RBC volume and adverse outcomes through multivariable logistic regression.

RESULTS

12,143 patients were analyzed, of which 3353 (27.6%) were transfused with 1-6U RBC intraoperatively. The incidence of death, overall morbidity, acute kidney injury and prolonged mechanical ventilation were increased stepwise along with incremental RBC volume. After adjusting for possible confounders, patients transfused with 1-2U were associated with a 1.42-fold risk of death (99% CI, 1.21-2.34, p = 0.01) compared with patients without RBC, patients with 3-4U were associated with a 1.57-fold risk (99% CI, 1.32-2.80, p = 0.005) and patients with 5-6U had a 2.26-fold risk of death (99% CI, 1.65-3.88, p < 0.001). Similarly, the incidence of overall morbidity, acute kidney injury and prolonged mechanical ventilation increased several folds as the RBC numbers increased.

CONCLUSIONS

There was a significant dose-dependent influence of incremental intraoperative RBC volume on increased risk of adverse outcomes for on-pump cardiac surgery patients. Patient blood management practice should aim to reduce not only transfusion rate but also the volume of blood use.

Use of four-factor prothrombin complex concentrate (4F-PCC) for management of bleeding not associated with therapeutic anticoagulant use

INTRODUCTION

Four-factor prothrombin complex concentrate (4F-PCC) may be an option for patients with bleeding unrelated to therapeutic anticoagulation to help with bleeding cessation and reduce blood component requirements.

MATERIALS AND METHODS

Retrospective, observational study of adult patients who received 4F-PCC for bleeding not associated with therapeutic anticoagulation between June 2019 and July 2021. Primary outcome was to describe off-label 4F-PCC use in patients not on therapeutic anticoagulation for bleeding management in surgical and non-surgical patients. Additional outcomes evaluated were blood product use, chest tube and drainage output, and coagulation studies before and after 4F-PCC administration as well as other hemostatic agent use and thromboembolic events.

RESULTS

Seventy-six patients were included; median age 64 years (IQR 50-69), 66% of bleeding events were associated with surgery, and the majority of 4F-PCC doses ordered by cardiac surgery (68.4%). A total of 110 4F-PCC doses were administered; median 1 dose/patient (IQR 1-2), median total dose 1000 units (IQR 500-1484). Other hemostatic agents commonly administered were protamine (59%), desmopressin (43%), and tranexamic acid (42%). Packed red blood cells, fresh frozen plasma, platelet, and cell saver blood administration and prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (aPTT) were significantly reduced following 4F-PCC administration. Eight patients (11%) experienced thromboembolic complications.

CONCLUSION

Relatively low doses of 4F-PCC (median total dose 1000 units) were associated with decreased blood component requirements and improved PT, INR, and aPTT values in patients with bleeding unrelated to therapeutic anticoagulation. Other hemostatic agent use was common and thromboembolic complications occurred.