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Mitigating the Risk: Transfusion or Reoperation for Bleeding After Cardiac Surgery
Chetan Pasrija1, Mehrdad Ghoreishi1, Glenn Whitman2
1Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
Insights
Reoperation after cardiac surgery increases morbidity, but substantial blood transfusion without reoperation poses a greater risk for complications like renal failure and mortality. Guided transfusion strategies may reduce these risks.
Area of Science:
- Cardiovascular Surgery
- Transfusion Medicine
- Surgical Outcomes Research
Background:
- Morbidity following cardiac surgery is linked to bleeding complications.
- Reoperation is often considered a marker for this morbidity.
- The comparative risks of reoperation versus substantial blood transfusion remain unclear.
Purpose of the Study:
- To compare the operative morbidity and mortality associated with reoperation versus substantial blood transfusion after cardiac surgery.
- To stratify patient outcomes based on the need for reoperation and the extent of blood transfusion.
Main Methods:
- Analysis of the Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (2011-2018) involving 23,240 patients.
- Patients were categorized into four groups: no reoperation/no substantial transfusion, reoperation/no substantial transfusion, no reoperation/substantial transfusion, and reoperation/substantial transfusion.
- Substantial transfusion was defined as exceeding median red blood cell (5 units) and non-red blood cell (4 units) requirements.
Main Results:
- Patients requiring reoperation were older with a higher predicted risk of mortality.
- Combined reoperation and substantial transfusion (Group 4) significantly increased odds of renal failure (OR 7.36), stroke (OR 3.24), and operative mortality (OR 8.68) compared to no reoperation/no transfusion (Group 1).
- Substantial transfusion without reoperation (Group 3) showed higher risks for renal failure (OR 3.48) and mortality (OR 2.91) than reoperation without substantial transfusion (Group 2).
Conclusions:
- While reoperation for bleeding is associated with increased morbidity, substantial transfusion without reoperation carries a comparable or greater risk.
- Optimizing the timing of reoperation and employing guided transfusion strategies may be crucial in mitigating morbidity.
- These findings suggest that substantial transfusion alone can be a significant driver of adverse outcomes post-cardiac surgery.
Background:
Several studies have established morbidity associated with bleeding after cardiac surgery. Although reoperation has been implicated as the marker for this morbidity, there remains limited understanding regarding relative morbidities of reoperation and substantial transfusion.
Methods:
The Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (July 2011-September 2018) was reviewed (N = 23,240). Substantial transfusion was defined as requiring greater than the reoperation group median red blood cells (5 units) and non-red blood cells (4 units). Patients were stratified into 4 subgroups: group 1, no reoperation without substantial transfusion (n = 22,365); group 2, reoperation without substantial transfusion (n = 351); group 3, no reoperation with substantial transfusion (n = 350); and group 4, reoperation with substantial transfusion (n = 167). Operative morbidity and mortality were compared.
Results:
Reoperation patients were older with a higher STS predicted risk of mortality (1.8% vs 1.2%, P < .001). Multivariable analysis demonstrated that group 4 increased the odds of renal failure (odds ratio [OR] 7.36, P < .001), stroke (OR 3.24, P = .002), and operative mortality (OR 8.68, P < .001) compared with group 1. Both group 2 and group 3 increased the odds of mortality and renal failure compared with group 1. However, group 3 had greater risk for renal failure (OR 3.48, P < .001) and mortality (OR 2.91, P < .001) than group 2.
Conclusions:
Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion reoperative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone.
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