Objectives: Reduction of cognitive function is a possible side effect after cardiac surgery. We investigated the effect of transfemoral versus conventional aortic valve replacement on cognitive performance early after surgery. Methods: 50 patients with transfemoral, catheter-based aortic valve implantations were compared to 50 patients with conventional surgical aortic valve replacement. Six neuropsychological subtests from the Syndrom Kurz Test and Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day in a double blind fashion. To assess the overall cognitive function and the degree of cognitive change across all tests after surgery we combined the six test-scores by principal component analysis. Results: The preoperative (S pre ), as well as postoperative (S post ) overall cognitive function scores, were not significantly different between the groups and showed deterioration within both groups (S pre conv. 0.2 ± 1.0 vs S post conv. −0.6 ± 1.1, p <0.0005 and S pre transfem. −0.2 ± 1.0 vs S post transfem. −0.6 ± 1.1, p = 0.002). This decline (S pre −Spost) was not associated with the type of operation (p = 0.1). Conclusion: Transfemoral aortic valve implantation has no cerebroprotective advantage since it leads also to an early postoperative decline of neuropsychological abilities, which is comparable to conventional aortic valve replacement.
Background
Adult cardiac surgery is often complicated by elevated blood losses that account for elevated transfusion requirements. Perioperative bleeding and transfusion of blood products are major risk factors for morbidity and mortality. Timely diagnostic and goal-directed therapies aim at the reduction of bleeding and need for allogeneic transfusions.
Methods
Single-centre, prospective, randomized trial assessing blood loss and transfusion requirements of 26 adult patients undergoing elective cardiac surgery at high risk for perioperative bleeding. Primary endpoint was blood loss at 24 h postoperatively. Random assignment to intra- and postoperative haemostatic management following either an algorithm based on conventional coagulation assays (conventional group: platelet count, aPTT, PT, fibrinogen) or based on point-of-care (PoC-group) monitoring, i.e. activated rotational thromboelastometry (ROTEM®) combined with multiple aggregometry (Multiplate®). Differences between groups were analysed using nonparametric tests for independent samples.
Results
The study was terminated after interim analysis (
n
= 26). Chest tube drainage volume was 360 ml (IQR 229-599 ml) in the conventional group, and 380 ml (IQR 310-590 ml) in the PoC-group (
p
= 0.767) after 24 h. Basic patient characteristics, results of PoC coagulation assays, and transfusion requirements of red blood cells and fresh frozen plasma did not differ between groups. Coagulation results were comparable. Platelets were transfused in the PoC group only.
Conclusion
Blood loss via chest tube drainage and transfusion amounts were not different comparing PoC- and central lab-driven transfusion algorithms in subjects that underwent high-risk cardiac surgery. Routine PoC coagulation diagnostics do not seem to be beneficial when actual blood loss is low. High risk procedures might not suffice as a sole risk factor for increased blood loss.
Trial registration
NCT01402739
, Date of registration July 26, 2011.
When added to existing pre-operative measures to reduce bacterial contamination of surgical incisions that are employed routinely at this cardiovascular surgery unit, use of antimicrobial skin sealant decreased the incidence of SSI in cardiac surgery patients.
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