The use of blood and blood products in aortic surgery is associated with adverse outcomes

doi:10.1016/j.jtcvs.2021.02.096

The Journal of Thoracic and Cardiovascular Surgery

Volume 165, Issue 2, February 2023, Pages 544-551.e3

https://doi.org/10.1016/j.jtcvs.2021.02.096 Get rights and content

Abstract

Objective

To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products.

Methods

All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival.

Results

A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001).

Conclusions

In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.

Graphical abstract

In propensity matched deep hypothermic circulatory arrest (DHCA) patients, blood product transfusion was associated with increased operative complications and higher overall mortality. RBC, Red blood cells; FFP, fresh frozen plasma.

Section snippets

Patient Population

This study was approved by the institutional review board of the University of Pittsburgh and need for written informed consent was waived. Our prospectively maintained cardiac surgical database was queried for circulatory arrest cases between 2010 and 2018. All proximal aortic surgery (hemiarch and total arch reconstructions) that required circulatory arrest were included. Descending thoracic aortic replacements were excluded. The transfusion blood or blood products included were packed red

Baseline Patient and Operative Characteristics

The total patient population consisted of 824 patients (Table E1) who required circulatory arrest. After propensity matching, the transfusion and no transfusion arms had 224 patients each. As expected, there were no differences (SMD < 0.15) for any matched baseline variables (see Table 1 for complete baseline comparison). This included age (61 vs 62 years; SMD = 0.01); the proportion of women (34.4% vs 33.9%; SMD = 0.01); rates of previous cardiovascular surgery (7.15% vs 9.82%; SMD = 0.08);

Discussion

Patients who undergo any type of cardiac surgery are at a heightened risk of blood loss and receipt of perioperative blood products.¹⁰^,²¹ Depending on the surgical center, the nature and status of the operative procedure, and the patient population, 27% to 92% of patients undergo postoperative blood transfusion.²²^,²³ Few studies have reported outcomes for patients requiring blood transfusion during DHCA and the literature consists of relatively limited patient population sizes.⁵^,¹²^,24, 25, 26,

Conclusions

Patients who underwent aortic surgery under DHCA and received perioperative blood product transfusion had poorer outcomes and significantly higher operative and long-term mortality compared with HCA patients who did not require blood products. Furthermore, blood product use was an independent predictor of mortality in this patient population. Even if the transfusion itself is not the cause of these adverse outcomes, the need for transfusion clearly indicates a poor prognosis for the patient. In

References (36)

J.E. Keenan et al.
Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement
J Thorac Cardiovasc Surg
(2016)
V. Mehta et al.
Reversal of coagulopathy with factor concentrates and autologous platelet rich plasma for aortic surgery with deep hypothermic circulatory arrest
J Cardiothorac Vasc Anesth
(2017)
S. Conolly et al.
Deep hypothermic circulatory arrest
Continuing Educ Anaesth Crit Care Pain
(2010)
D.J. LaPar et al.
Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery
J Thorac Cardiovasc Surg
(2013)
A. Kilic et al.
Blood transfusions in cardiac surgery: indications, risks, and conservation strategies
Ann Thorac Surg
(2014)
V. Bianco et al.
Reoperative cardiac surgery is a risk factor for long-term mortality
Ann Thorac Surg
(2020)
G.J. Arnaoutakis et al.
The impact of deep versus moderate hypothermia on postoperative kidney function after elective aortic hemiarch repair
Ann Thorac Surg
(2016)
K.A. Dufendach et al.
Distal extent of surgery for acute type A aortic dissection
Oper Tech Thorac Cardiovasc Surg
(2019)
B.D. Speiss
Transfusion and outcome in heart surgery
Ann Thorac Surg
(2002)
M. Nelson et al.
Measurement of blood loss in cardiac surgery: still too much
Ann Thorac Surg
(2018)

J. Fassl et al.

Transfusion of allogeneic blood products in proximal aortic surgery with hypothermic circulatory arrest: effect of thromboelastometry-guided transfusion management

J Cardiothorac Vasc Anesth

(2013)

E. Girdauskas et al.

Thromboelastometrically guided transfusion protocol during aortic surgery with circulatory arrest: a prospective, randomized trial

J Thorac Cardiovasc Surg

(2010)

Y. Wang et al.

Comparison of two different red blood cell transfusion thresholds on short-term clinical outcomes of patients undergoing aortic surgery with deep hypothermic circulatory arrest

J Cardiothorac Vasc Anesth

(2016)

J.B. Williams et al.

Predictors of massive transfusion with thoracic aortic procedures involving deep hypothermic circulatory arrest

J Thorac Cardiovasc Surg

(2011)

B. Bhaskar et al.

Impact of blood product transfusion on short and long-term survival after cardiac surgery: more evidence

Ann Thorac Surg

(2012)

D.R. Gerber

Risks of packed red blood cell transfusion in patients undergoing cardiac surgery

J Crit Care

(2012)

M.C. Engoren et al.

Effect of blood transfusion on long-term survival after cardiac operation

Ann Thorac Surg

(2002)

A. Damberg et al.

Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest

J Thorac Cardiovasc Surg

(2017)

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To evaluate the effect of perioperative allogeneic packed red blood cell (RBC) transfusion during aortic root replacement.
We reviewed patients undergoing aortic root replacement at our institution between March 2014 and April 2020. In total, 760 patients underwent aortic root replacement, of whom 442 (58%) received a perioperative RBC transfusion. Propensity score matching was used to account for baseline and operative differences resulting in 159 matched pairs. All-cause mortality was assessed with Kaplan–Meier curves. Data were obtained from our institutional Society of Thoracic Surgeons database and chart review.
After propensity score matching, the RBC-transfused and -nontransfused groups were similar for all preoperative characteristics. Cardiopulmonary bypass time, crossclamp time, and lowest operative temperature were similar between the transfused and nontransfused groups (standardized mean difference <0.05). RBC transfusion was associated with more frequent postoperative ventilation greater than 24 hours (36/159 [23%] vs 19/159 [12%]; P = .01), postoperative hemodialysis (9/159 [5.7%] vs 0/159 [0%]; P = .003), reoperation for mediastinal hemorrhage (9/159 [5.7%] vs 0/159 [0%]; P = .003), and longer intensive care unit and hospital length of stay (3 vs 2 days and 8 vs 6 days respectively; P < .001). Thirty-day operative mortality after propensity score matching was similar between the cohorts (1.9%; 3/159 vs 0%; P = .2), and 5-year survival was reduced in the RBC transfusion cohort (90.2% [95% confidence interval, 84.1%-96.7%] vs 97.1% [95% confidence interval, 92.3%-100%] P = .035).
Aortic root replacement frequently requires RBC transfusion during and after the operation, but even after matching for observed preoperative and operative characteristics, RBC transfusion is associated with more frequent postoperative complications and reduced midterm survival.
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: Accepted for the American Association for Thoracic Surgery Aortic Symposium 2020.

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Adult: AortaThe use of blood and blood products in aortic surgery is associated with adverse outcomes

Abstract

Objective

Methods

Results

Conclusions

Graphical abstract

Section snippets

Patient Population

Baseline Patient and Operative Characteristics

Discussion

Conclusions

J Thorac Cardiovasc Surg

J Cardiothorac Vasc Anesth

Continuing Educ Anaesth Crit Care Pain

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Oper Tech Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Thorac Cardiovasc Surg

J Cardiothorac Vasc Anesth

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Crit Care

Ann Thorac Surg

J Thorac Cardiovasc Surg

Adult: Aorta
The use of blood and blood products in aortic surgery is associated with adverse outcomes