Complications associated with preoperative anemia, perioperative bleeding and blood transfusions after isolated coronary artery bypass grafting

Abstract Cardiovascular diseases are the leading cause of death worldwide, and coronary artery disease accounts for the majority of them. The treatment of choice for complex coronary artery disease is coronary artery bypass grafting. However, as surgery in general, cardiac surgery is associated with an increased risk of perioperative bleeding and utilization of blood products. The present study aimed to investigate the impact of preoperative anemia, perioperative bleeding and retained blood syndrome as well as blood transfusion on the outcomes after isolated coronary surgery. The severity of perioperative bleeding was assessed mainly using the E-CABG and UDPB stratification criteria. Our analyses showed that severe bleeding is associated with a significantly increased risk of stroke. Furthermore, severe bleeding increased the risk of several adverse events even in low-risk patients. Retained blood syndrome was observed to be a common complication after coronary surgery and was associated with an increased risk of postoperative complications. Preoperative anemia seems to have no significant impact on patient early and late survival. Instead, the frequent exposure to blood products may be the determinant of poorer survival observed among anemic patients. Perioperative blood loss and exposure to allogeneic blood has been shown to increase adverse events. Therefore, prevention of bleeding and measures to optimize patient blood management could improve patient outcomes after cardiac surgery.Tiivistelmä Sydän ja verisuonitaudit ovat maailmanlaajuisesti yleisin kuoleman aiheuttaja, joista sepelvaltimotaudilla on suurin vaikutus. Sepelvaltimoiden ohitusleikkaus on käypä hoito vakavassa sepelvaltimotaudissa. Kuten kirurgiassa yleisestikin, erityisesti sydänkirurgia on yhdistetty suurentuneeseen verenevuodon ja verituotteiden saannin riskiin. Tutkimukseni tavoitteena oli selvittää preoperatiivisen anemian, perioperatiivisen verenvuodon, verituotteiden annon, sekä leikkausalueelle jääneen veren itsenäisiä vaikutuksia potilaiden lopputulemiin sepelvaltimoiden ohitusleikkauksen jälkeen. Verituotteiden ja perioperatiivisen verenvuodon määrää arvioitiin pääsääntöisesti käyttäen E-CABG ja UDPB verenvuotoluokituksia. Tuloksenamme oli, että vakava verenvuoto lisää merkitsevästi aivoinfarktin riskiä. Lisäksi vakava perioperatiivinen verenvuoto on yhteydessä useisiin komplikaatioihin myös matalan leikkausriskin potilailla. Leikkausalueelle jääneen veren huomattiin olevan yleinen ongelma sepelvaltimoiden ohitusleikkauksen jälkeen, minkä lisäksi se lisäsi riskiä useille haitta-tapahtumille. Preoperatiivisella anemialla ei ollut tilastollisesti merkitsevää vaikutusta potilaiden lyhyen ja pitkän aikavälin ennusteisiin. Sen sijaan, aneemisille potilaille annetut verensiirrot saattaisivat aiheuttaa näillä potilailla huomatun alentuneen elinajan ennusteen. Perioperatiivisen verenvuodon ja altistumisen verituotteille on osoitettu lisäävän haittatapahtumia. Siispä verenvuodon vähentäminen ja verituotteiden säästäminen voisi parantaa potilaiden ennustetta sydänkirurgiassa

The effect of preoperative anemia on the outcome after coronary surgery

Abstract Background: Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery. Since anemia is ultimately treated with red blood cell transfusions, we investigated the independent impact of anemia and transfusion on the outcome after coronary artery bypass grafting (CABG). Methods: This study included 2761 consecutive patients who underwent isolated CABG. Anemia was defined as hemoglobin <12.0 g/dL in women and <13.0 g/dL in men. The main outcomes were 30-day and late mortality. Results: Patients with preoperative anemia had an increased prevalence of significant comorbidities and were associated with higher unadjusted risk of early and late adverse events. Propensity score matching resulted in 560 pairs with similar baseline and operative characteristics. In these matched pairs, anemic patients had an increased risk of late all-cause death (P = 0.047) and acute kidney injury (P < 0.0001). However, when adjusted for the severity of perioperative bleeding, preoperative anemia was not associated with an increased mortality risk (HR 1.10, 95% CI 0.86–1.39). Instead, this regression model showed that the European CABG registry (E-CABG) bleeding classification was an independent predictor of late mortality (compared to grade 0: grade 1, HR 1.93, 95% CI 1.37–2.73, grade 2, HR 2.19, 95% CI 1.50–3.18, grade 3, HR 5.59, 95% CI 3.34–9.39, P < 0.0001). Conclusions: When adjusted for important baseline characteristics and operative factors as well as for the severity of perioperative bleeding and the amount of transfused blood products, anemia was not associated with an increased risk of adverse events. Increased exposure to blood transfusion among anemic patients may be the determinant of their poorer late survival

Transfusion and blood stream infections after coronary surgery

Abstract The aim of this study was to evaluate the impact of blood transfusion on bloodstream infections. This study included 2764 patients who underwent isolated coronary artery bypass grafting. Blood cultures were drawn in 27.9% of patients and were positive in 3.5% of them. Blood transfusion before blood cultures were drawn (4.7% vs 1.2%, odds ratio 3.75, 95% confidence interval 1.11–12.67) and deep sternal wound infection/mediastinitis (20.0% vs 2.8%, odds ratio 7.43, 95% confidence interval 2.72–20.32) were independent predictors of a positive postoperative blood culture. Positive blood culture increased the risk of 5-year mortality (among patients with blood cultures drawn: 44.7% vs 19.6%, adjusted hazard ratio 2.10, 95% confidence interval 1.18–3.71). Exposure to blood products may increase the risk of bloodstream infection after cardiac surgery. Positive blood cultures after coronary artery bypass grafting are associated with poor late survival. These findings require validation in prospective studies

Meta-analysis of the sources of bleeding after adult cardiac surgery

Abstract Objective: The aim of this study was to pool data on the proportion and prognostic impact of sources of bleeding in patients requiring re-exploration after adult cardiac surgery. Design: Systematic review of the literature and meta-analysis. Setting: Multistitutional study. Measurements and Main Results: A literature review was performed to identify studies published since 1990 evaluating the outcome after reoperation for bleeding or tamponade after adult cardiac surgery. Eighteen studies including 5,1497 patients fulfilled the selection criteria. Reoperation for bleeding/tamponade was performed in 2,455 patients (4.6%; 95% confidence interval [CI] 3.9%–5.2%, I² 92%). These had a significantly higher risk of in-hospital/30-day mortality compared with patients not reoperated for bleeding (pooled rates: 9.3% v 2.3%; risk ratio 3.30; 95% CI 2.52–4.32; I² 47%; 8 studies; 25,463 patients). Surgical sites of bleeding were identified in 65.7% of cases (95% CI 58.3%–73.2%; I² 94%), cardiac site bleeding in 40.9% of cases (95% CI 29.7%–52.0%; I² 94%), and mediastinal/sternum site bleeding in 27.0% of cases (95% CI 16.8%–37.3%; I² 94%). The main sites of bleeding were the body of the graft (20.2%), the sternum (17.0%), vascular sutures (12.5%), the internal mammary artery harvest site (13.0%), and anastomoses (9.9%). In metaregression, surgical site bleeding was associated with a lower risk of in-hospital/30-day mortality compared with diffuse bleeding (p = 0.003). Conclusions: Surgical site bleeding is identified in two-thirds of patients undergoing re-exploration after adult cardiac surgery. Meticulous surgical technique and systematic intraoperative checking of potential surgical sites of bleeding at the time of the original cardiac surgery may reduce the risk of such a severe complication

Poor acetabular component orientation increases revision risk in metal-on-metal hip arthroplasty

Abstract Background: The rate of and the reasons for the failure of metal-on-metal (MoM) bearings have recently been discussed in literature. The aim of this study was to evaluate the influence of acetabular cup inclination and version angles on revision risk in patients with MoM hip arthroplasty. Methods: We retrospectively reviewed 825 patients (976 hips) who underwent a MoM hip arthroplasty between 2000 and 2013. There were 474 men and 351 women, with a mean age of 58 (19–86) years. Acceptable cup orientation was considered to be inside the Lewinnek′s safe zone. Results: The mean acetabular inclination angle was 48.9° (standard deviation, 8.1°; range, 16°–76°) and version angle 20.6° (standard deviation, 9.9°; range, −25 to 46°). The cup was found to be outside the Lewinnek′s safe zone in 571 hips (58.5%). Acetabular cup revision surgery was performed in 157 hips (16.1%). The cup angles were outside Lewinnek′s safe zone in 69.2% of the revised hips. The mean interobserver reliability and intraobserver repeatability of the measurements of cup inclination and version angles were excellent (intraclass correlation coefficients > 0.90). The odds ratio for revision in hips outside vs inside the Lewinnek′s safe zone was 1.82 (95% confidence interval, 1.26–2.62; P = 0.0014). Conclusions: Our findings provide compelling evidence that a cup position outside the Lewinnek′s safe zone is associated with increased revision risk in patients with MoM arthroplasty

Outcome after procedures for retained blood syndrome in coronary surgery

Abstract OBJECTIVES: Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac surgery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: A total of 2764 consecutive patients who underwent isolated CABG from 2006 to 2013 were investigated retrospectively. Patients undergoing any procedure for RBS were compared with patients who did not undergo any procedure for RBS. Multivariate analyses were performed to assess the impact of procedures for RBS on the early outcome. RESULTS: A total of 254 patients (9.2%) required at least one procedure for RBS. Multivariate analysis showed that RBS requiring a procedure for blood removal was associated with significantly increased 30-day mortality [8.3% vs 2.7%, odds ratio (OR) 2.11, 95% confidence interval (95% CI) 1.15–3.86] rates. Procedures for RBS were independent predictors of the need for postoperative antibiotics (51.6% vs 32.1%, OR 2.08, 95% CI 1.58–2.74), deep sternal wound infection/mediastinitis (6.7% vs 2.2%, OR 3.12, 95% CI 1.72–5.66), Kidney Disease: Improving Global Outcomes acute kidney injury (32.7% vs 15.3%, OR 2.50, 95% CI 1.81–3.46), length of stay in the intensive care unit (mean 8.3 vs 2.0 days, beta 1.74, 95% CI 1.45–2.04) and composite major adverse events (21.3% vs 6.9%, OR 3.24, 95% CI 2.24–4.64). These findings were also confirmed in a subgroup of patients with no pre- or postoperative unstable haemodynamic conditions. CONCLUSION: RBS requiring any procedure for blood removal from pericardial and pleural spaces is associated with an increased risk of severe complications after isolated CABG

Perioperative bleeding requiring blood transfusions is associated with increased risk of stroke after transcatheter and surgical aortic valve replacement

Abstract Objectives: The authors aimed to investigate the impact of severe bleeding and use of red blood cell (RBC) transfusion on the development of postoperative stroke after surgical (SAVR) and transcatheter aortic valve replacement (TAVR), taken from the FinnValve registry. Design: Nationwide, retrospective observational study. Setting: Five Finnish university hospitals participated in the registry. Participants: A total of 6,463 patients who underwent SAVR (n = 4,333) or TAVR (n = 2,130). Interventions: Patients who underwent TAVR or SAVR with a bioprosthesis with or without coronary revascularization. Measurements and Main Results: The incidence of postoperative stroke after SAVR was 3.8%. In multivariate analysis, the number of transfused RBC units (odds ratio [OR], 1.098; 95% confidence interval [CI], 1.064–1.133) was one of the independent predictors of postoperative stroke. The incidence of stroke increased, along with the severity of perioperative bleeding, according to the European Coronary Artery Bypass Grafting (E-CABG) bleeding grades were as follows: grade 0, 2.2% (reference group); grade 1, 3.4% (adjusted OR, 1.841; 95% CI, 1.105–3.066); grade 2, 5.5% (adjusted OR, 3.282; 95% CI, 1.948–5.529); and grade 3, 14.8% (adjusted OR, 7.103; 95% CI, 3.612–13.966). The incidence of postoperative stroke after TAVR was 2.5%. The number of transfused RBC units was an independent predictor of stroke after TAVR (adjusted OR, 1.155; 95% CI, 1.058–1.261). The incidence of postoperative stroke increased, along with the severity of perioperative bleeding, as stratified by the E-CABG bleeding grades: E-CABG grade 0, 1.7%; grade 1, 5.3% (adjusted OR, 1.270; 95% CI, 0.532–3.035); grade 2, 10.0% (adjusted OR, 2.898; 95% CI, 1.101–7.627); and grade 3, 30.0% (adjusted OR, 10.706; 95% CI, 2.389–47.987). Conclusions: Perioperative bleeding requiring RBC transfusion and/or reoperation for intrathoracic bleeding is associated with an increased risk of postoperative stroke after SAVR and TAVR. Patient blood management and meticulous preprocedural planning and operative technique aiming to avoid significant perioperative bleeding may reduce the risk of cerebrovascular complications

Mid-term outcomes of Sapien 3 versus Perimount Magna Ease for treatment of severe aortic stenosis

Abstract Background: There is limited information on the longer-term outcome after transcatheter aortic valve replacement (TAVR) with new-generation prostheses compared to surgical aortic valve replacement (SAVR). The aim of this study was to compare the mid-term outcomes after TAVR with Sapien 3 and SAVR with Perimount Magna Ease bioprostheses for severe aortic stenosis. Methods: In a retrospective study, we included patients who underwent transfemoral TAVR with Sapien 3 or SAVR with Perimount Magna Ease bioprosthesis between January 2008 and October 2017 from the nationwide FinnValve registry. Propensity score matching was performed to adjust for differences in the baseline characteristics. The Kaplan-Meir method was used to estimate late mortality. Results: A total of 2000 patients were included (689 in the TAVR cohort and 1311 in the SAVR cohort). Propensity score matching resulted in 308 pairs (STS score, TAVR 3.5 ± 2.2% vs. SAVR 3.5 ± 2.8%, p = 0.918). In-hospital mortality was 3.6% after SAVR and 1.3% after TAVR (p = 0.092). Stroke, acute kidney injury, bleeding and atrial fibrillation were significantly more frequent after SAVR, but higher rate of vascular complications was observed after TAVR. The cumulative incidence of permanent pacemaker implantation at 4 years was 13.9% in the TAVR group and 6.9% in the SAVR group (p = 0.0004). At 4-years, all-cause mortality was 20.6% for SAVR and 25.9% for TAVR (p = 0.910). Four-year rates of coronary revascularization, prosthetic valve endocarditis and repeat aortic valve intervention were similar between matched cohorts. Conclusions: The Sapien 3 bioprosthesis achieves comparable midterm outcomes to a surgical bioprosthesis with proven durability such as the Perimount Magna Ease. However, the Sapien 3 bioprosthesis was associated with better early outcome