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Bleeding Complications in Patients With Perioperative COVID-19 Infection Undergoing Cardiac Surgery: A Single-Center
Giovanni A Chiariello1, Piergiorgio Bruno1, Natalia Pavone1
1Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy.
Insights
Patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery face a significantly higher risk of bleeding complications. This increased risk, including reoperations and transfusions, necessitates careful consideration in operative risk assessment.
Area of Science:
- Cardiovascular Surgery
- Infectious Diseases
- Hematology
Background:
- Previous studies indicate poor outcomes for patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery, with common complications including respiratory and renal failure, and thromboembolic events.
- Recent observations highlight a particularly high incidence of bleeding complications in this patient population.
Purpose of the Study:
- To investigate the correlation between perioperative COVID-19 infection and hemorrhagic complications in patients undergoing cardiac surgery.
- To compare bleeding risks in COVID-19 positive patients versus those without COVID-19 infection.
Main Methods:
- A retrospective, matched case-control study was conducted.
- 23 patients with perioperative COVID-19 infection undergoing open-heart surgery on cardiopulmonary bypass (CPB) were matched with 46 control patients without COVID-19.
- Data collected included bleeding complications, reoperations for bleeding, thrombocytopenia, blood component transfusions, and hemostasis time.
Main Results:
- Patients with COVID-19 exhibited a significantly higher incidence of bleeding complications (48% vs. 2%, p=0.0001) and surgical reexploration for bleeding (35% vs. 2%, p=0.0001).
- COVID-19 patients also showed a higher incidence of severe postoperative thrombocytopenia (39% vs. 6%, p=0.0007) and a greater need for blood transfusions (74% vs. 30%, p=0.0006).
- Prolonged chest tube blood loss and surgical hemostasis time were observed in the COVID-19 group.
Conclusions:
- Perioperative COVID-19 infection is associated with a significantly increased risk of early and late bleeding complications after cardiac surgery.
- The findings suggest that the inflammatory response related to CPB may exacerbate COVID-19's effects on coagulation, leading to a hemorrhagic pattern.
- This heightened bleeding risk must be factored into the preoperative assessment of patients undergoing cardiac surgery.
Objective:
Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients.
Design:
Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection.
Setting:
Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area.
Participants:
In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score.
Interventions:
Open-heart cardiac surgery on CPB.
Measurements And Main Results:
In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively).
Conclusions:
A worrisome increased risk of early and late bleeding complications in COVID-19 patients was observed, and it should be considered when assessing the operative risk. CPB-related inflammatory reaction could exacerbate the deleterious effect of COVID-19 on the coagulation system and likely deviate it toward a hemorrhagic pattern.
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