Blood transfusion in cardiac surgery does increase the risk of 5‐year mortality: results from a contemporary series of 1714 propensity‐matched patients

Shaw, Richard E.; Johnson, Christopher K.; Ferrari, Giovanni; Brizzio, Mariano E.; Sayles, Kathleen; Rioux, Nancy; Zapolanski, Alex; Grau, Juan B.

doi:10.1111/trf.12364

Cited by 55 publications

(49 citation statements)

References 32 publications

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“…There is ample evidence that RBC transfusion may directly contribute to adverse clinical outcomes in cardiac surgery. [28, 29] While the mechanisms by which transfusions elicit injurious responses remain unknown, there appears to be a distinct inflammatory component. [30] Apart from anaphylactic transfusion reactions, MC activation has been reported due to immunoglobulin E oligomers in donor plasma[31], however future studies will have to determine if MCs are also involved in mediating a more general inflammatory response to transfusion.…”

Section: Discussionmentioning

confidence: 99%

Mast cell activation and arterial hypotension during proximal aortic repair requiring hypothermic circulatory arrest

Kertai

Cheruku

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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Objective Aortic surgeries requiring hypothermic circulatory arrest evoke systemic inflammatory responses that often manifest as vasoplegia and hypotension. Because mast cells can rapidly release vasoactive and pro-inflammatory effectors, we investigated their role in intraoperative hypotension. Methods We studied 31 patients undergoing proximal aortic repair with hypothermic circulatory arrest between June 2013 and April 2015 at Duke University Medical Center. Plasma samples were obtained at different intraoperative time-points to quantify chymase, IL6, IL8, TNFa, and white blood cell CD11b expression. Hypotension was defined as the area [minutes * mmHg] below a mean arterial pressure of 55 mmHg. Biomarker responses and their association with intraoperative hypotension were analyzed by two sample t test and Wilcoxon rank sum test. Multivariable logistic regression analysis was used to examine the association between clinical variables and elevated chymase levels. Results Mast cell-specific chymase increased from a median 0.97 [interquartile range, 0.01 to 1.84] pg/mg plasma protein at baseline to 5.74 [2.91 to 9.48] pg/mg plasma protein after instituting cardiopulmonary bypass, 6.16 [3.60 to 9.41] pg/mg plasma protein after completing of circulatory arrest and 7.64 [4.63 to 12.71] pg/mg plasma protein after weaning from cardiopulmonary bypass (each p<0.0001 vs baseline). Chymase was the only biomarker associated with hypotension during (p = 0.0255) and after cardiopulmonary bypass (p = 0.0221). Increased temperatures at circulatory arrest and low pre-surgical hemoglobin levels were independent predictors of increased chymase responses. Conclusion Mast cell activation occurs in cardiac surgery requiring cardiopulmonary bypass and hypothermic circulatory arrest and is associated with intraoperative hypotension.

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Section: Discussionmentioning

confidence: 99%

Mast cell activation and arterial hypotension during proximal aortic repair requiring hypothermic circulatory arrest

Kertai

Cheruku

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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“…Blood transfusion during or after cardiac surgery is associated with increased morbidity and mortality, and guidelines to conserve blood products in non‐Witness patients have shown improved outcomes and reduced costs . Although the literature has demonstrated that bloodless cardiac surgery is possible and potentially beneficial to patients, it requires preoperative optimization and a multidisciplinary team.…”

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confidence: 99%

Jehovah's Witnesses and cardiac surgery: a single institution's experience

et al. 2014

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Background Based on biblical doctrines, patients of the Jehovah's Witness faith refuse allogeneic blood transfusion. Cardiac surgery carries a high risk of blood transfusion, but has been performed in Jehovah's Witnesses for many years. The literature contains information on the outcomes of this cohort, but does not detail the perioperative care of these patients. This article describes a single institution's experience in perioperative care of Jehovah's Witnesses undergoing cardiac surgery. Study Design and Methods A chart review of adult Jehovah's Witness patients undergoing cardiac surgery at Duke University between January 2005 and June 2012 was completed. Institutional protocols regarding preoperative erythropoietin (EPO) therapy and intraoperative isovolemic hemodilution are detailed. Patient demographics and use of various blood conservation techniques are described. Hemoglobin (Hb) at various points throughout the perioperative management, hospital length of stay, and mortality are reviewed as indicators of outcome. Results Forty‐five Jehovah's Witness patients underwent cardiac surgery at Duke University Medical Center. Preoperative EPO increased the mean Hb by 1.2 g/dL before surgery. Intraoperative normovolemic hemodilution was used in 37 patients with intraoperative mean nadir Hb of 10.3 g/dL. Antifibrinolytics and desmopressin were commonly used as coagulation adjuncts. Mean cardiopulmonary bypass time was 137 minutes, with mean nadir temperature of 30.5°C. The mean length of hospital stay was 6.2 days, with mean intensive care unit stay of 1.7 days. This cohort had zero 90‐day mortality in the perioperative period. Conclusions This case series demonstrates that bloodless cardiac surgery can be performed in select patients refusing allogeneic blood transfusion.

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“…4 Several factors have been shown to be independently associated with transfusion in cardiac surgery patients. These include age, 5 gender, pre-operative haemoglobin concentration (Hb), elevated plasma creatinine 3 and low body weight.…”

Section: Introductionmentioning

confidence: 99%

The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery

Klein

Collier

Yeates

et al. 2017

British Journal of Anaesthesia

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Objective: To derive a simple and accurate scoring system to predict risk of transfusion for patients undergoing cardiac surgery Design: Retrospective analysis of data collected from the ACTA National Audit; for the derivation dataset, we included data from 20,036 patients, which we then externally validated using a further group of 1,047 patients. Methods:We identified independent risk factors associated with transfusion by performing univariate analysis, followed by logistic regression. We then simplified the score to aninteger-based system and tested it using AUC characteristic statistic. A Hosmer-Lemeshow goodness-of-fit test was applied. Finally, the scoring system was applied to the external validation dataset and the same statistical methods applied to test the accuracy of the ACTA-PORT score.Results: Several factors were shown to be independently associated with risk of transfusion.These included age, gender, body surface area, logistic EuroSCORE, preoperative haemoglobin and creatinine, and type of surgery. In our primary dataset, the score accurately predicted risk of perioperative transfusion in cardiac patients with an AUC of 0.76. The external validation confirmed the accuracy of the scoring method with an AUC of 0.84 and good agreement across all scores with a minor tendency to under-estimate transfusion risk in very high-risk patients. Conclusion:The ACTA-PORT score is a reliable, validated tool for predicting the risk of transfusion for patients undergoing cardiac surgery. This score will allow clinicians to easily identify patients at increased risk for transfusion and apply patient blood management strategies appropriately, with the potential to reduce perioperative morbidity and mortality.

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Blood transfusion in cardiac surgery does increase the risk of 5‐year mortality: results from a contemporary series of 1714 propensity‐matched patients

Abstract: Blood transfusion, specifically cryoprecipitates, was independently associated with increased 5-year mortality. Transfusion during cardiac surgery should be limited to patients who are in critical need of blood products.

Cited by 55 publications

References 32 publications

Mast cell activation and arterial hypotension during proximal aortic repair requiring hypothermic circulatory arrest

Mast cell activation and arterial hypotension during proximal aortic repair requiring hypothermic circulatory arrest

Jehovah's Witnesses and cardiac surgery: a single institution's experience

The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery

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