30-day Bleeding Research Articles

Abstract 4136704: Comparison of Early Clinical Outcomes with Balloon-Expanding Valves Versus Self-Expanding Valves in Transcatheter Aortic Valve Replacement: A Meta-Analysis of Randomized Controlled Trials

Background: Transcatheter aortic valve replacement (TAVR) is an effective percutaneous intervention in patients with severe aortic stenosis, particularly in those with contraindications for surgical repair. Currently, two types of aortic valves are used in clinical practice: balloon-expanding valves (BEV) and self-expanding valves (SEV). The current data comparing early (30-day) clinical outcomes of BEV to SEV in patients with severe aortic stenosis undergoing TAVR are inconsistent. Methods: A systematic literature search spanning PubMed, Embase, Cochrane, and Scopus databases was conducted to retrieve randomized controlled trials (RCTs) comparing balloon-expanding valves to self-expanding valves in patients undergoing TAVR. The DerSimonian and Laird random-effects model was used to pool the odds ratios (OR) with 95% confidence intervals. Statistical significance was set at p<0.05. Results: This meta-analysis included five RCTs with 2190 severe aortic stenosis patients (1097 in the BEV group and 3621 in the SEV group). BEV-TAVR was associated with a significantly lower risk of 30-day new permanent pacemaker (PPM) implantation [OR: 0.67; 95% CI: 0.48, 0.93; p=0.02] and 30-day re-hospitalization for heart failure [OR: 0.20; 95% CI: 0.04, 0.96; p=0.04] compared to SEV-TAVR. The risks of 30-day mortality, 30-day cardiac mortality, 30-day all-cause stroke, 30-day myocardial infarction, 30-day life-threatening bleeding, 30-day vascular complications, 30-day acute kidney injury, and 30-day repeat procedures for valve-related dysfunction were comparable between the two groups. Conclusion: TAVR in patients with severe aortic stenosis using BEV is advantageous over SEV in terms of 30-day new PPM implantation and 30-day rehospitalization for heart failure, with comparable risks for other outcomes. These findings underscore the safety and efficacy of newer generation valves, including Sapien 3 and EvolutPro, in TAVR. The choice of prosthetic aortic valve is dependent on individual anatomy and operator preference. Further RCTs are warranted to evaluate other newer-generation valves with varying severities of aortic stenosis.

Validation of Artificial Intelligence-Based POTTER Calculator in Emergency General Surgery Patients Undergoing Laparotomy: Prospective, Bi-Institutional Study.

The POTTER calculator, a widely used interpretable artificial intelligence (AI) risk calculator, has been validated in population-based studies and shown to predict outcomes in emergency general surgery (EGS) patients better than surgeons. We sought to prospectively validate POTTER. Patients undergoing an emergency exploratory laparotomy for non-trauma indications at two Academic Medical Centers between June 2020 and March 2022 were included. POTTER preoperative risk calculations and postoperative outcomes were systematically recorded. POTTER's performance in predicting 30-day postoperative mortality, septic shock, respiratory failure, bleeding, and pneumonia was assessed using the c-statistic methodology. A total of 361 patients were included. The median age was 63 years (IQR: 51-72), 45.4% were females, and the overall mortality and morbidity were 24.1% and 51.4%, respectively. POTTER predicted mortality accurately with a c-statistic of 0.90. POTTER also accurately predicted the occurrence of individual postoperative complications, with c-statistics ranging between 0.80 and 0.89. This is the first prospective validation of the AI-enabled POTTER calculator. The superior accuracy, user-friendliness, and interpretability of POTTER make it a useful bedside tool for preoperative patient and family counseling.

S1008 Percutaneous Coronary Intervention in Cancer Patients: Assessing 30-Day Bleeding Readmissions

S1008 Percutaneous Coronary Intervention in Cancer Patients: Assessing 30-Day Bleeding Readmissions

Peak Procedural ACT Is Associated With All-Cause Mortality After Femoral Access PCI

BackgroundA minimum threshold activated clotting time (ACT) to guide heparin dosing during percutaneous coronary intervention (PCI) is associated with lower ischemic complications. However, data are variable regarding the risk of high ACT levels. The aim of this study was to assess the impact of peak procedural ACT on complications and mortality for transfemoral and transradial access PCI. MethodsThe UC San Diego Health National Cardiovascular Data Registry CathPCI Registry was used to obtain data on patients who underwent native vessel PCI from January 2007 to September 2022. Coronary artery bypass graft patients and those who received bivalirudin were excluded. Complications and all-cause mortality at 30 days and 1-year post-PCI were assessed by ACT tertile. ResultsA total of 2473 patients (age 65 ± 12 years; 74% male) undergoing PCI with 53% femoral and 47% radial access were included. The majority (82%) had 1-vessel coronary artery disease with heterogeneous clinical presentations (21.8% ST-elevation myocardial infarction, 25.4% non–ST-elevation myocardial infarction, 4.9% unstable angina, 33.8% stable angina, 3.4% atypical chest pain, 10.7% other indication for PCI). With femoral access, patients in the third tertile (ACT ≥ 275) had significantly higher all-cause mortality at 30 days (5.3% vs 2.7% vs 0.9%; P < .001), 6 months (6.3% vs 4.0% vs 2.0%; P = .007), and 1 year (9.0% vs 6.0% vs 2.7%; P < .001) compared to the second (ACT 228-275) and first tertile (ACT ≤ 228), respectively. A 30-day landmark analysis revealed that there was no difference in all-cause mortality beyond 30 days (3.9% vs 3.4% vs 1.8%; P = .176). There were increased bleeding complications in the highest tertile (12.8% vs 9.8% vs 7.5%; P = .034) and a higher need for blood products (10.4% vs 6.7% vs 5.4%; P = .014). There was no difference in ischemic major adverse cardiovascular events specifically periprocedural myocardial infarction or stroke between tertiles. There was no difference in clinical outcomes by peak ACT for patients who had radial access. ConclusionsHigher ACT with transfemoral access PCI was associated with increased 30-day mortality, bleeding complications, and need for blood products post-PCI.

Comparative Efficacy of Wound Drainage and Non-Drainage in Posterior Spinal Surgery

Background: The recent trend has been toward recommendation of nondrainage in spinal surgery. However, the use of drains following posterior spinal surgery is still controversial. It has been claimed that wound drainage confers no significant advantages, increases the risk of infection and the need for blood transfusion with the attendant risks of this therapy. Suction drainage is used to minimize infection, prevention of wound swelling, improvement of the local wound environment, prevent hematoma and /or seroma formation. The aim of this study was to determine the incidence of post-operative complications after posterior lumbar instrumentation with and without a subfascial drain. Methods: This is prospective analysis of 32 adult (≥18 years old) spine patients that underwent elective and emergency posterior lumbar instrumentation at Kathmandu Medical College Teaching Hospital, from January to December 2023. There were randomly assigned 16 (50%) patients who had a post-operative drain and 16 (50%) patients who did not have a postoperative drain (No-Drain: n=16; Drain-Use: n=16). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was pain, the need for post-operative transfusion, dressing changes, surgery – discharge interval, the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation. Data was analyzed using SPSS statistics version 29 (IBM Corp., New York). Results: Our study revealed that no significant differences regarding wound infection (P = 1), hematoma, neurological injury, estimated blood loss (P = 0.3), or dry and moderate dressing drainage between the groups. There were no 30-day hospital readmission or incidence of 30-day wound dehiscence, draining wound or bleeding between both patient groups. Conclusions: There is no obvious advantage of the application of suction drains for spinal surgery. There was no significant difference in the rate of infection or wound healing and no patient developed a postoperative neurologic deficit. However, a decision of wound drainage or wound non-drainage should be individualized for each patient because many factors affect the outcomes.

Reduced mortality associated with pulmonary embolism response team consultation for intermediate and high-risk pulmonary embolism: a retrospective cohort study

BackgroundThe management of acute pulmonary embolism (PE) has become increasingly complex with the expansion of advanced therapeutic options, resulting in the development and widespread adoption of multidisciplinary Pulmonary Embolism Response Teams (PERTs). Much of the literature evaluating the impact of PERTs has been limited by pre- postimplementation study design, leading to confounding by changes in global practice patterns over time, and has yielded mixed results. To address this ambiguity, we conducted a retrospective cohort study to evaluate the impact of the distinct exposures of PERT availability and direct PERT consultation.MethodsAt a single tertiary center, we conducted propensity-matched analyses of hospitalized patients with intermediate or high-risk PE. To assess the impact of PERT availability, we evaluated the changes in 30-day mortality, hospital length of stay (HLOS), time to therapeutic anticoagulation (TAC), in-hospital bleeding complications, and use of advanced therapies between the two years preceding and following PERT implementation. To evaluate the impact of direct PERT consultation, we conducted the same analyses in the post-PERT era, comparing patients who did and did not receive PERT consultation.ResultsSix hundred eighty four patients were included, of which 315 were pre-PERT patients. Of the 367 postPERT patients, 201 received PERT consultation. For patients who received PERT consultation, we observed a significant reduction in 30-day mortality (5% vs 20%, OR 0.38, p = 0.0024), HLOS.(-5.4 days, p < 0.001), TAC (-0.25 h, p = 0.041), and in-hospital bleeding (OR 0.28, p = 0.011).These differences were not observed evaluating the impact of PERT presence in pre-vs postimplementation eras.ConclusionsWe observed a significant reduction in 30-day mortality, hospital LOS, TAC, and in-hospital bleeding complications for patients who received PERT consultation without an observed difference in these metrics when comparing the pre- vs post-implementation eras. This suggests the benefits stem from direct PERT involvement rather than the mere existence of PERT. Our data supports that PERT consultation may provide benefit to patients with acute intermediate or high-risk PE and can be achieved without a concomitant increase in advanced therapies.

Prevalence of bleeding events in real-world Japanese registry for Percutaneous Ventricular Assist Device.

Bleeding complication is a critical risk factor for outcomes of acute heart failure patients requiring mechanical circulatory support (MCS), including percutaneous catheter-type heart pumps (Impella). The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) is an ongoing, large-scale, real-world registry to characterize Japanese patients requiring Impella. Here we analyzed bleeding complication profiles in patients who received Impella. All consecutive Japanese patients who received Impella from October 2017 to January 2020 were enrolled. The 30-day survival and bleeding complications were analyzed. A total of 1344 patients were included: 653 patients received Impella alone, 685 patients received a combination of veno-arterial extracorporeal membrane oxygenation and Impella (ECPELLA), and 6 patients had failed Impella delivery. Overall 30-day survival was 67.0%, with Impella alone at 81.9% and ECPELLA at 52.7%. Overall bleeding/hematoma adverse events with a relation or not-excluded relation to Impella was 6.92%. Among them, the rates of hematoma and bleeding from medical device access sites were 1.41% and 4.09%, respectively. There was no difference between etiologies for these events. This study represents the first 3-year survival and the safety profile focused on bleeding adverse events from the J-PVAD registry. The results show that the real-world frequency of bleeding adverse events for patients who received Impella was an expected range from previous reports, and future real-world studies should aim to expand this data set to improve outcomes and adverse events.

Emergent Esophagectomy in Patients with Esophageal Malignancy Is Associated with Higher Rates of Perioperative Complications but No Independent Impact on Short-Term Mortality.

Data on perioperative outcomes of emergent versus elective resection in esophageal cancer patients requiring esophagectomy are lacking. We investigated whether emergent resection was associated with increased risks of morbidity and mortality. Data on patients with esophageal malignancy who underwent esophagectomy from 2005 to 2020 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Thirty-day complication and mortality rates were compared between emergent esophagectomy (EE) and non-emergent esophagectomy. Logistic regression assessed factors associated with complications and mortality. Of 10,067 patients with malignancy who underwent esophagectomy, 181 (1.8%) had EE, 64% had preoperative systemic inflammatory response syndrome, sepsis, or septic shock, and 44% had bleeding requiring transfusion. The EE group had higher American Society of Anesthesiologists (ASA) class and functional dependency. More transhiatal esophagectomies and diversions were performed in the EE group. After EE, the rates of 30-day mortality (6.1% vs. 2.8%), overall complications (65.2% vs. 44.2%), bleeding, pneumonia, prolonged intubation, and positive margin (17.7% vs. 7.4%) were higher, while that of anastomotic leak was similar. On adjusted logistic regression, older age, lower albumin, higher ASA class, and fragility were associated with increased complications and mortality. McKeown esophagectomy and esophageal diversion were associated with a higher risk of postoperative complications. EE was associated with 30-day postoperative complications (odds ratio, 2.39; 95% confidence interval, 1.66-3.43; p<0.0001). EE was associated with a more than 2-fold increase in complications compared to elective procedures, but no independent increase in short-term mortality. These findings may help guide data-driven critical decision-making for surgery in select cases of complicated esophageal malignancy.

Impact of heart failure severity and major bleeding events after percutaneous coronary intervention on subsequent major adverse cardiac events

Abstract Background Heart failure (HF) is one of high bleeding risk after percutaneous coronary intervention (PCI). Furthermore, major bleeding events increase the risk of subsequent cardiovascular events. However, it is unknown whether HF severity and bleeding events are associated with major adverse cardiac events (MACE). Purpose The aim of this study was investigating the impact of HF severity or bleeding events on subsequent MACE. Methods Clinical Deep Data Accumulation System (CLIDAS), a multicenter database with 7 tertiary medical hospitals, was developed to collect data directly for patient characteristics, medications, laboratory test, physiological test, cardiac catheterization and PCI treatment in electronic medical records. This retrospective analysis included 7,160 patients with PCI between April 2014 and March 2020 and have completed 3-year follow-up. The patients were divided into two groups: HF with high BNP (HF-hBNP) (&amp;gt;100 pg/ml) (n=384) and non-HF-hBNP (HF with low BNP and non-HF) (n=6,776). Furthermore, both groups were re-classified into two groups according to presence of major bleeding events in 30 days: HF-hBNP with 30-day bleeding (n=14), without 30-day bleeding (n=370), non-HF-hBNP with 30-day bleeding (n=74) and without 30-day bleeding (n=6,702). Primary endpoint was defined as MACE. Results HF with high BNP was an independent risk factor of MACE (hazard ratio [HR], 2.21; 95% confidence interval [CI], 1.64-2.98) compared with non-HF. Among the HF-hBNP patients, MACE incidence tended to be increased by 30-day bleeding (p=0.075). In addition, among the non-HF-hBNP patients, the bleeding events increased the risk of MACE (p=0.003). The multivariable Cox regression model revealed that other three groups were associated with a high risk compared with non-HF-hBNP without 30-day bleeding group: non-HF-hBNP with 30-day bleeding (HR, 3.90; 95% CI, 1.59-9.54), HF-hBNP without 30-day bleeding (HR, 2.19; 95% CI, 1.56-3.07) and HF-hBNP with 30-day bleeding (HR, 8.33; 95% CI, 2.57-27.0). Conclusion The real-world database CLIDAS revealed that HF with high BNP and major bleeding events in 30 days might be associated with MACE. Those results suggest that management of HF and prevention of bleeding complication in early days after PCI could be important to prevent MACE.

Postoperative Discharge Destination Impacts 30-Day Outcomes: A National Surgical Quality Improvement Program Multi-Specialty Surgical Cohort Analysis.

Surgical patients can be discharged to a variety of facilities which vary widely in intensity of care. Postoperative readmissions have been found to be more strongly associated with post-discharge events than pre-discharge complications, indicating the importance of discharge destination. We sought to evaluate the association between discharge destination and 30-day outcomes. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were dichotomized based on discharge destination: home versus non-home. The main outcome of interest was 30-day unplanned readmission. The secondary outcomes included post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. In this cohort study of over 1.5 million patients undergoing common surgical procedures across eight surgical specialties, we found non-home discharge to be associated with adverse 30-day post-operative outcomes, namely, unplanned readmissions, post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. Non-home discharge is associated with worse 30-day outcomes among patients undergoing common surgical procedures. Patients and caregivers should be counseled regarding discharge destination, as non-home discharge is associated with adverse post-operative outcomes.

Comparison of outcomes of self-expanding versus balloon-expandable valves for transcatheter aortic valve replacement: a meta-analysis of randomized and propensity-matched studies

BackgroundThe postoperative outcomes of transcatheter aortic valve replacement (TAVR) with the new generation of self-expanding valves (SEV) and balloon-expandable valves (BEV) remain uncertain.MethodsWe conducted a meta-analysis based on randomized controlled trials (RCTs) and propensity score-matched (PSM) studies to evaluate the performance of the new generation TAVR devices, with a focus on Edwards SAPIEN 3/Ultra BEV, Medtronic Evolut R/PRO SEV, and Boston ACURATE neo SEV. Our primary endpoints were mortality and complications at both 30 days and one year post-operation.ResultsA total of 4 RCTs and 14 PSM studies were included. Our findings showed no significant difference between SEV and BEV regarding 30-day and 1-year mortality rates. ACURATE SEV required less permanent pacemaker implantation (PPI) at 30-day as compared to SAPIEN BEV, while Evolut SEV required a higher rate of PPI than SAPIEN BEV. The incidence of stroke, major or life-threatening bleeding (MLTB), major vascular complications (MVC), coronary artery obstruction (CAO) and acute kidney injury (AKI) did not differ significantly between the two groups. SEV had a larger effective orifice area (EOA) and lower mean transvalvular gradients (MPG) compared to BEV. However, there was an increased risk of paravalvular leakage (PVL) associated with SEV.ConclusionsIn terms of 30-day mortality, stroke, bleeding, MVC, AKI, CAO, and one-year mortality, there was comparability between the two valve types following TAVR. SEV was associated with better hemodynamic outcomes, except for a higher incidence of PVL. Compared to SAPIEN BEV, ACURATE SEV had a lower risk of PPI at 30 days, while Evolut SEV was associated with a higher risk of PPI. These findings underscore the importance of personalized valve selection.

Urgent versus Non-Urgent Transcatheter Aortic Valve Implantation Outcomes

Introduction: There are limited data about the outcomes of nonelective transcatheter aortic valve implantation (TAVI). Some studies suggest that these patients (pts) have worst results. Our purpose was to compare outcomes in pts submitted to urgent versus elective TAVI. Methods: Retrospective analysis of 298 consecutive pts submitted to TAVI between 2018 and 2021 in a single tertiary center. Baseline characteristics and outcomes were collected and compared between elective and nonelective TAVI. Results: Pts submitted to urgent TAVI (79 pts) had worse baseline characteristics, with higher EuroScore risk (9.26 vs. 5.17%, p < 0.0001), STS score (7.09 vs. 4.4%, p < 0.0001), and NT pro-natriuretic peptide B (10,168 vs. 3,241 pg/mL, p = 0.001), lower left ventricle ejection fraction (45 vs. 52%, p = 0.003), more diabetes (46.8 vs. 32.4%, p = 0.0.22), peripheral artery disease (21.5 vs. 6.8%, p < 0.0001), and poor vascular accesses (18.4 vs. 7.4%, p = 0.007). Urgent TAVI was associated with higher mortality (25.3 vs. 15.1%, p = 0.043), 30-day cardiovascular mortality (17.5 vs. 4%, p = 0.001), life-threatening bleeding (11.5 vs. 4.1%, p = 0.018), vascular complications (11.5 vs. 4.6%, p = 0.031), and longer hospital stay (28 vs. 12 days, p < 0.0001), but not with intensive care unit or post-TAVI hospital stay (5 vs. 4 days, p = 0.197 and 11 vs. 10 days, p = 0.572). When adjusted to differences in baseline characteristics, urgent TAVI was only associated with longer hospital stay (p < 0.0001). Conclusion: Pts submitted to urgent TAVI have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics instead of the urgent nature of the procedure.

Impact of heart failure severity and major bleeding events after percutaneous coronary intervention on subsequent major adverse cardiac events

BackgroundHeart failure (HF) is associated with a high bleeding risk after percutaneous coronary intervention (PCI). Additionally, major bleeding events increase the risk of subsequent major adverse cardiac events (MACE). However, whether brain natriuretic peptide (BNP) levels and major bleeding events following PCI are associated with MACE and all-cause death remains unknown. This study aimed to investigate the impact of HF severity or bleeding on subsequent MACE and all-cause death. MethodsThe Clinical Deep Data Accumulation System (CLIDAS), a multicenter database involving seven hospitals in Japan, was developed to collect data from electronic medical records. This retrospective analysis included 7160 patients who underwent PCI between April 2014 and March 2020 and completed a three-year follow-up. Patients were divided according to the presence of HF with high BNP (HFhBNP) (>100 pg/ml) and major bleeding events within 30 days post-PCI (30-day bleeding): HFhBNP with bleeding (n = 14), HFhBNP without bleeding (n = 370), non-HFhBNP with bleeding (n = 74), and non-HFhBNP without bleeding (n = 6702). ResultsIn patients without 30-day bleeding, HFhBNP was a risk factor for MACE (hazard ratio, 2.19; 95% confidence interval, 1.56–3.07) and all-cause death (hazard ratio, 1.60; 95% confidence interval, 1.60–2.23). Among HFhBNP patients, MACE incidence was higher in patients with 30-day bleeding than in those without bleeding, but the difference was not significant (p = 0.075). The incidence of all-cause death was higher in patients with bleeding (p = 0.001). ConclusionsHF with high BNP and bleeding events in the early stage after PCI might be associated with subsequent MACE and all-cause death.

The Safety and Effectiveness of the Prostar XL Closure Device Compared to Open Groin Cutdown for Endovascular Aneurysm Repair.

The aim of this study is to compare the outcomes of percutaneous femoral closure with the Prostar XL for endovascular aneurysm repair (EVAR) to those of open femoral cutdown, and to evaluate factors which may predict the failure of percutaneous closure. Patients undergoing endovascular aneurysm repair for an infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. Patient characteristics, anatomic femoral artery measurements, and postoperative complications were recorded retrospectively. Operator experience was defined with a cut-off point of >30 Prostar XL closures performed. Comparisons were made per access site. A total of 443 access sites were included, with percutaneous closure used in 257 cases (58.0%) and open cutdown in 186 cases (42.0%). The complication rate was 2.7% for the percutaneous and 4.3% for the open cutdown group (P = .482). No significant differences between groups were found with respect to 30-day mortality, wound infections, thrombosis, seromas, or bleeding complications. Fourteen failures (5.4%) of percutaneous closure occurred. The success rates were similar for experienced and unexperienced operators (94.2% vs 95.5%, P = .768). Renal insufficiency was more common in the failed than in the successful percutaneous closure group (64.3% vs 24.7%, P = .003). Common femoral artery calcification or diameter, BMI, sheath size, or operator experience did not predict failure. No further complications were seen in follow-up CT at 1-3years postoperatively. The use of the Prostar XL is safe compared to open cutdown. The success rate is 94.6%. Operator experience, sheath size, obesity, or femoral artery diameter or calcification do not appear to predict a failure of percutaneous closure. Complications seem to occur perioperatively, and late complications are rare.

Incidence of 30-day Bleeding Events in Acute Coronary Syndrome Patients Treated With Intra-Aortic Balloon Pump

Incidence of 30-day Bleeding Events in Acute Coronary Syndrome Patients Treated With Intra-Aortic Balloon Pump

A randomized controlled trial to investigate the use of acute coronary syndrome therapy in patients hospitalized with COVID-19: the COVID-19 Acute Coronary Syndrome trial

BackgroundPatients hospitalized with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. ObjectivesTo investigate the efficacy of an acute coronary syndrome regimen in patients hospitalized with COVID-19 and coronary disease risk factors. MethodsA randomized controlled, open-label trial across acute hospitals (United Kingdom and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28 days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, or death). ResultsThree hundred twenty patients from 9 centers were randomized. The trial terminated early due to low recruitment. At 30 days, there was no significant difference in mortality (intervention vs control, 11.5% vs 15%; unadjusted odds ratio [OR], 0.73; 95% CI, 0.38-1.41; p = .355). Significant bleeds were infrequent and were not significantly different between the arms (intervention vs control, 1.9% vs 1.9%; p > .999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR, 1.46; 95% credible interval [CrI], 0.88-2.37; Pr [beta > 0], 93%; adjusted OR, 1.50; 95% CrI, 0.91-2.45; Pr [beta > 0], 95%) and median time to discharge to home was 2 days shorter (95% CrI, −4 to 0; 2% probability that it was worse). ConclusionAcute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.

Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis

Study objectiveIt has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty. DesignPropensity-matched cohort analysis. SettingAmerican College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021. PatientsPatients undergoing elective total hip arthroplasty (n = 223,060). InterventionsNone. MeasurementsThe a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses. Main resultsThe 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, −0.09 [95% CI, −0.12 to −0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021. ConclusionsTotal hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.

The Usage of Intravenous Tranexamic Acid in Reduction Mammaplasty Safely Reduces Hematoma Rates.

Bleeding complications are not uncommon after breast reduction surgery, and recently, tranexamic acid (TXA) as an antifibrinolytic agent has been used in various surgical specialties as a way to minimizes such adverse outcomes. We elected to evaluate the effectiveness of intravenous (IV) intraoperative TXA in reduction mammoplasty patients. This is a retrospective chart review of clinical charts of all patients who received reduction mammoplasty by a single surgeon at Emory University Hospital or its affiliated Aesthetic Center from January 1, 2020, to March 1, 2022. Seventy-four consecutive breast reduction patients received 1-g IV TXA intraoperatively compared with 117 consecutive controls. The outcome of interest included 30-day postoperative bleeding complications. There was no significant difference in age ( P = 0.92), body mass index ( P = 0.98), percentage of smokers ( P = 0.56), operating time ( P = 0.87), estimated blood loss ( P = 0.90), or weight removed ( P = 0.98) between patients in each arm. There were 19 bleeding events (16.2%) in the non-TXA arm compared with 1 bleeding event (1.4%) in the TXA arm ( P = 0.0143). Of the 19, 6 (5.1%) were major events, and 13 were minor events (11.1%); the only bleeding event in the TXA arm was minor. Number needed to treat all bleeding events with use of TXA was 7, and the number needed to treat minor hematomas was 11. There was no significant difference in the rate of seroma, wound healing complications, infection, or nipple necrosis between the 2 arms ( P > 0.05). The use of IV TXA is a safe and effective way to reduce hematoma rates in patients receiving reduction mammoplasty.

Impact of Fried Frailty Phenotype on Postoperative Outcomes After Durable Contemporary Mechanical Circulatory Support: A Single-Center Experience.

Frailty is prevalent in advanced heart failure patients and may help distinguish patients at risk of worse outcomes. However, the effect of frailty on postoperative clinical outcomes is still understudied. Therefore, we aim to study the relationship between frailty and postoperative clinical outcomes in patients undergoing long-term mechanical circulatory support (MCS). Forty-six patients undergoing durable MCS (left ventricular assist device and total artificial heart) placement at our medical center were assessed for frailty pre-implant. Frailty was defined as ≥ 3 physical components of the Fried frailty phenotype. Our primary endpoint is 1 year of survival post-implant. Secondary endpoints include 30-day all-cause rehospitalization, pump thrombosis, neurological event (stroke/transient ischemic attack), gastrointestinal bleeding, and driveline infection within 12 months post-MCS support. Of the 46 patients, 32 (69%) met the criteria for frailty according to Fried. The cohort's median age was 67.0 years. The frail group had statistically significant lower left ventricular ejection fraction (LVEF) (11% vs. 20%, P = 0.017) and lower albumin (3.5 vs. 4.0 g/dL, P = 0.021). The frail cohort also had significantly higher rates of comorbid chronic kidney disease (47% vs. 7%, P = 0.016). There were no differences between the frail vs. non-frail group in terms of 30-day readmission rates (40% vs. 39%, P = 0.927) and 1-year post-intervention survival (log-rank, P = 0.165). None of the other secondary endpoints reached statistical significance, although the incidence of gastrointestinal bleed (24% vs. 16%, P = 0.689) and pump thrombosis (8% vs. 0%, P = 0.538) were higher in the frail group. Preoperative Fried frailty was not associated with readmission at 30 days, mortality at 365 days, and other postoperative outcomes in long-term durable MCS patients. Findings may need further validation in larger studies.

Timing and safety of hip fracture surgery in patients on direct-acting oral anticoagulants

BackgroundMany geriatric patients presenting for emergency hip fracture surgery are on direct oral anticoagulants (DOACs) most of which are not easily reversible. A safe policy was required to reduce delays to surgery. Prior to institution of our hospital's protocol in January 2021, most of these patients had surgery after 48 h following the last dose of DOAC due to concerns about increased perioperative blood loss. MethodsThis was a prospective closed loop audit of the protocol-surgery within 24 h from last dose of DOAC (if creatinine clearance >50 ml/min) with administration of 1-g of tranexamic acid at anesthesia induction. 131 eligible patients (DOAC, n = 22; no anticoagulation, n = 109) between January–June 2021 who had emergency hip fracture surgery were identified. Primary outcome measures were peri-operative blood loss, transfusion requirements and policy compliance. Secondary outcome measures were 30-day mortality, thrombotic complications and wound bleeding. ResultsCompliance with surgical timing and tranexamic acid administration were 55% and 81% respectively after the second audit cycle. The mean estimated blood loss (EBL) in the DOAC group versus the non-anticoagulated control group was 500 ml and 330 ml respectively. The difference between these groups was statistically significant at an alpha level of 5% (P = 0.0115, 95% CI 38.48–299.16). The difference for intra-operative (RR 3.43; 95% CI 1.68–7.01) and post-operative blood transfusion (RR 2.10; 95% CI 1.23–3.58) for the 2 groups was also statistically significant. However, there was no case of massive blood transfusion in both groups. The DOAC group had a lower risk for 30-day mortality (RR 0.71; 95% CI 0.09-5.46). There was no major thrombotic complication in the DOAC group. ConclusionThis audit has shown that this protocol is safe although clinicians should anticipate some degree of increased intra-operative blood loss. We will recommend continuation of this policy with sustained safety monitoring in order to reduce delays to surgery.